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Foundations II Articles to edit

Palliative sedation

• Find alternative guidelines for statistics on palliative sedation outside of the UK (VT)
• Add more information to the "Policies" section (look up US guidelines)(VT)

REVIEW ARTICLE VOLUME 36, ISSUE 3, P310-333, SEPTEMBER 01, 2008 https://www.jpsmjournal.com/article/S0885-3924(08)00100-0/fulltext#secd29292811e2287

Palliative Sedation: A Review of the Research Literature : Patricia Claessens, RN, PhD (C) , Johan Menten, MD, PhD, Paul Schotsmans, PhD, Bert Broeckaert, PhD

Open Archive Published:July 28, 2008 DOI:https://doi.org/10.1016/j.jpainsymman.2007.10.004

Systematic Review in English, French, German, and Dutch on research articles about important aspects of palliative sedation:

Prevalence of Palliative Sedation

• In a review of research articles on various aspects of palliative care, the prevalence of palliative sedation was reported as highly varied. In palliative care units or hospice, the prevalence ranged from 3.1%-51%. In the home care setting, two Italian studies reported a prevalence of 25% and 52.5%. Hospital-based palliative support teams vary in prevalence, with reports of 1.33% and also 26%. Different countries also report large differences in prevalence of palliative sedation:
• Netherlands - 10%
• Belgium - 8.2%
• Italy - 8.5%
• Denmark - 2.5%
• Switzerland - 4.8%
• Sweden - 3%
• Almost half of the studies reviewed differentiated intermittent versus continuous palliative sedation. The prevalence of intermittent sedation was 30% -67% of cases and continuous sedation was 14-68% of cases. Patients starting intermittent sedation may progress to use of continuous sedation in 10 - 27% of cases. The prevalence of mild versus deep sedation was also reported: one study reported 51% of cases used mild sedation and 49% deep sedation; another study reported 80% of cases used mild sedation and 20% deep sedation.

Survival of patients: There are reports that after initiation of palliative sedation, 38% of patients died within 24 hours and 96% of patients died within one week. Other studies report a survival time of < 3 weeks in 94% of patients after starting palliative sedation. Some physicians estimate that this practice shortens life by ≤24 hours for 40% of patients and > 1 week for 27% of patients. Another study reported patients receiving sedation in their last week of life survived longer than those who did not receive sedation, or only received sedation during last 48 hours of life.

• Our review revealed that the prevalence of palliative sedation varied considerably (Table 3, Table 4), especially in terms of setting, definition, and methodology used. Most of the studies were carried out in palliative care units or hospices. The prevalence in these settings ranged between 3.1%10 and 51%.37 In two Italian studies 12,  51 performed in home care environments almost 10 years apart, one study reported a prevalence of 52.5% and the other reported a prevalence of 25%. We also found a large difference in prevalence among hospital-based palliative support teams. Stone et al.,31 for example, reported a prevalence of 26%, whereas Menten10 reported a prevalence of only 1.33%. Prevalence of palliative sedation also varied across countries. Two studies reported palliative sedation prevalence as a proportion of all deaths in one of six European countries.28,  36 For the Netherlands,28,  43 Belgium,36 and Italy,36 the prevalence was 10%, 8.2%, and 8.5%, respectively. In Denmark, Switzerland, and Sweden, a much lower prevalence of 2.5%, 4.8, and 3%, respectively, was reported.36
• 41 percent of the studies distinguished between intermittent and continuous palliative sedation. Intermittent sedation was reported in 30%–67% of cases, whereas continuous sedation was reported in 14%–69% of cases. Morita et al.49 reported that 51% of patients received mild sedation and 49% deep sedation. In a second study,48 they reported that 80% of patients received mild sedation, whereas 20% received deep sedation. In several studies, intermittent sedation sometimes resulted in continuous sedation at the end of life. This was the case in between 10% and 27% of the patients that had started with intermittent sedation.10,  32,  37,  44 An interesting finding about the beliefs of the lay public and professionals was reported in the study of Morita et al.54 While examining the conceptual validity of the proposed criteria for palliative sedation, they found that both physicians and the general population differentiate mild sedation and intermittent deep sedation from standard medical care. Moreover, they reported that physicians consider continuous deep sedation to be close in practice to both mild and intermittent deep sedation. However, the general population considered it to be closer to euthanasia/physician-assisted suicide.
• Survival of Patients After the Initiation of Palliative Sedation Half of the reviewed studies reported on the survival of patients after palliative sedation.9,  28,  29,  30,  32,  37,  42,  44,  45,  46,  48,  49,  50 Based on retrospective reports from physicians, Rietjens et al.28,  30 found that 38% of patients died within 24 hours, whereas 96% of patients died within one week.
  • According to physicians' estimations, palliative sedation shortened life
    • by ≤24 hours for 40% of patients,
    • by > 1 week for 27% of patients, 27,  29
• Morita et al.41,  42 reported a survival time of less than three weeks in 94% of the patients receiving palliative sedation. Mean survival of patients after the onset of palliative sedation ranged from one to six days.9,  10,  28,  30,  32,  37,  44,  45,  46,  47,  48,  49,  50 Other studies compared the survival of sedated and nonsedated patients.12,  31,  37,  44,  58,  61 In accordance with other papers, Vitetta et al.59 found no differences in survival time between sedated and nonsedated patients.12,  31,  37,  44,  58,  61 Moreover, no relationship could be found between survival and the individual physician's prescribing pattern.59 The paper of Sykes and Thorns,58 however, found that the survival time of patients receiving sedation throughout their last week of life was significantly longer (P<0.001) than those who did not receive sedation and those who did receive sedation during the last 48 hours of their life.59

The practice of palliative sedation has been a a topic of debate and controversy because many view it as a form of slow euthanasia or mercy killing, associated with many ethical questions. Discussion of this practice occurs in medical literature, but there is no consensus because there are no clear definitions and guidelines, with many differences in practice across the world.

Introduction section from same review

For more than 10 years, palliative sedation has been a much debated and controversial issue within and outside the field of palliative care. Some authors have described it as a form of slow euthanasia or mercy killing in disguise.16,  18,  19,  20,  21 According to these authors, palliative sedation is highly problematic and is associated with many important ethical questions. Despite a very extended theoretical discussion in the medical literature, most of these questions remain unanswered due to the lack of conceptual clarity, clear definitions and guidelines, and the huge number of contradictions in the international empirical literature on the subject.

Reflections on palliative sedation, Robert Twycross

https://journals.sagepub.com/doi/full/10.1177/1178224218823511

Nearly 30 years ago, the Division of Pain Therapy and Palliative Care at the National Cancer Institute in Milan reported that of patients cared for at home, 63 out of 120 patients had unendurable symptoms which were relieved only by sedation-inducing sleep.1 On average, such symptoms appeared 2 days before death. Other centres indicated that this was not their experience,2,3 and thus began an ongoing discussion about sedation at the end of life.4,5

Initially referred to as ‘terminal sedation’,6 the term fell into disrepute because of potential ambiguity: did the word ‘terminal’ relate to the patient or the sedation? ‘Palliative sedation’ (PS) was considered preferable because it emphasized that the aim was palliation (to relieve symptoms) and not to terminate life and was defined as follows:

The intentional administration of sedative drugs in dosages and combinations required to reduce the consciousness of a terminal patient as much as necessary to adequately relieve one or more refractory symptoms.7

up to date

Administration — Sedation for the management of refractory symptoms is usually performed in an inpatient setting. However, substantial experience has been reported in home care settings [59], which may be a reasonable alternative for some patients.

Administration and Monitoring

Palliative sedation is administered commonly in the inpatient setting, but also reported to be performed in home care settings. The medication prescribed for palliation will need dose titration to initially manage the refractory symptoms and relieve suffering, and therapy will continue to maintain adequate effect. Sedation administration can be both continuous and intermittent, and the route chosen may be intravenous, intramuscular, subcutaneous, or rectal, depending on the patient. When breakthrough symptoms occur, the patient will need emergency bolus therapy to maintain symptom management. Both mild or deep levels of sedation may be used to provide relief from suffering, with deeper levels used when death is imminent and a catastrophic event has occurred.

The patient will be monitored during palliative sedation to maintain adequate symptom relief, but the following clinical situations will determine need for dose titration:

• Patient is at end-of-life: Vitals are not monitored except for respiratory rate to assess respiratory distress and tachypnea. The goal is to achieve comfort, so downward titration of sedation is not recommended due to risk of recurrent distress.
• Patient is nearing end-of-life: Vitals such as heart rate, blood pressure, and oxygen saturation, are monitored to maintain physiological stability through sedation. Depending on the risk of patient to have respiratory depression or become unstable, the treatment dose may need to be adjusted or a benzodiazepine antagonist may be administered.
• Suffering managed and symptom controlled: Sedation may be carefully lowered for lucidity. This would provide possibility of reevaluating the patient's preferences for care or allow patient-family communication. If lucidity is not re-established, symptoms may arise and death prevent further care.

Administration of the selected medication initially requires dose titration to achieve adequate relief, followed by ongoing therapy to ensure maintenance of the effect. In general, the level of sedation should be the least necessary to provide adequate relief of suffering. Regular, "around the clock" administration can be maintained by continuous infusion or intermittent bolus.

The route of administration can be intravenous, intramuscular, subcutaneous, or rectal; in some situations, drugs can also be administered via a stoma or gastrostomy. In all cases, provision for emergency bolus therapy to manage breakthrough symptoms is recommended.

If mild sedation is ineffective, deeper levels of sedation should be performed. This is especially true in cases of refractory suffering when death is imminent and in the case of a catastrophic event (eg, massive hemorrhage or asphyxia). (See "Palliative care: Overview of cough, stridor, and hemoptysis", section on 'Management'.)

Patient monitoring — Once adequate relief has been achieved, the parameters for patient monitoring and the role of further dose titration are determined by the clinical situation:

●Patient is imminently dying – We do not perform routine monitoring of vital signs (eg, pulse, blood pressure, and temperature) for patients nearing death. The only critical parameters for ongoing observation are those pertaining to comfort. Since downward titration of drug doses places the patient at risk for recurrent distress, it is not recommended in most instances. Respiratory rate is monitored primarily to ensure the absence of respiratory distress and tachypnea. A gradual deterioration of respiration is expected as patients near death and this alone should not constitute a reason to decrease sedation.

●Patient is not imminently dying – Monitoring may be undertaken to preserve physiological stability for terminally ill patients who are not imminently dying. This may include repeat assessment of the level of sedation and routine physiological parameters such as heart rate, blood pressure, and oxygen saturation. If life-threatening obtundation with respiratory depression occurs, a lower treatment dose may be required. If patients become more unstable, the careful administration of a benzodiazepine antagonist (flumazenil) may be appropriate.

●Once sedation and symptom control is achieved, doses can be titrated down to reestablish lucidity if appropriate, if this was desired by the patient prior to sedation. This enables an opportunity to reevaluate the patient's condition and their preferences regarding sedation. It may also allow for patient-family communication. However, lucidity may not be restored, symptoms may reoccur, and death may intervene.

Palliative Care Policy in East and Southern Africa

Palliative Care in Disease-Specific Policies

HIV epidemic lead to many terminally ill people who needed palliative care, causing many governments and HIV programs to develop palliative care programs and strategic plans. The following countries have these policies enacted implement the use of palliative care in the national responses.

• Kenya: "Kenya National AIDS Strategic Plan 2005/2006–2009/2010" and "National Cancer Control Plan of 2011–2016"
• Uganda: "Uganda National HIV Strategic Plan 2007/2008–2011/2012," "Uganda Cancer Institute Act of 2016," and "Uganda National Cervical Cancer Control plan"
  • "Ugandan National Health Sector Plan 2015/2016–2019/2020"
• Tanzania: "United Republic of Tanzania National Cancer Control Strategy of 2013–2022".
• Zimbabwe: "Zimbabwe National HIV and AIDS Strategic Plan of 2015–2018" and "Zimbabwe National Cancer Control Strategy 2013–2017"
• Malawi: "Malawi National HIV and AIDS Strategic Plan (2011–2016)" under strategy 2.5
• The Kingdom of Swaziland: "Second National Multisectoral HIV and AIDS Strategic Plan 2006–2008"

The African Palliative Care Association has worked with the health ministries of Malawi, Tanzania, Rwanda, Swaziland, Zimbabwe, Botswana, Mozambique, and Uganda to develop health policies that include palliative care.

National Stand-Alone Palliative Care Policies

Other Legal FrameworksPediatric Palliative Care Policy

Esophageal atresia

• Who/What/Where are the 1 in 3,000 live births discussed in the epidemiology section (VT)
• Re-organize signs and symptoms listed in epidemiology section into "Signs and Symptoms" section (VT)

Epidemiology ( Lewis Spitz, University College, London)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1884133/pdf/1750-1172-2-24.pdf

Oesophageal atresia is a relatively common congenital malformation occurring in one in 2500–3000 live births. ****not cited**** The overwhelming majority of cases of oesophageal atresia are sporadic/non-syndromic, although a small number within this non-familial group are associated with chromosomal abnormalities. Familial/syndromic cases of oesophageal atresia are extremely rare, representing less than 1% of the total. Oesophageal atresia is 2 to 3 times more common in twins [1].

Pictoral classification of esophageal atresia

Prevalence of Esophageal Atresia among 18 International Birth Defects Surveillance Programs

Natasha Nassar et al https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4467200/METHODS

The study population comprised infants diagnosed with EA during 1998 to 2007 from 18 of the 46 birth defects surveillance programs, members of the International Clearinghouse for Birth Defects Surveillance and Research. Total prevalence per 10,000 births for EA was defined as the total number of cases in live births, stillbirths, and elective termination of pregnancy for fetal anomaly (ETOPFA) divided by the total number of all births in the population.

RESULTS

Among the participating programs, a total of 2943 cases of EA were diagnosed with an average prevalence of 2.44 (95% confidence interval [CI], 2.35–2.53) per 10,000 births, ranging between 1.77 and 3.68 per 10,000 births. Of all infants diagnosed with EA, 2761 (93.8%) were live births, 82 (2.8%) stillbirths, 89 (3.0%) ETOPFA, and 11 (0.4%) had unknown outcomes. The majority of cases (2020, 68.6%), had a reported EA with fistula, 749 (25.5%) were without fistula, and 174 (5.9%) were registered with an unspecified code.

CONCLUSIONS

On average, EA affected 1 in 4099 births (95% CI, 1 in 3954–4251 births) with prevalence varying across different geographical settings, but relatively consistent over time and comparable between surveillance programs. Findings suggest that differences in the prevalence observed among programs are likely to be attributable to variability in population ethnic compositions or issues in reporting or registration procedures of EA, rather than a real risk occurrence difference.

Epidemiology of esophageal atresia

R. Sfeir et al https://academic.oup.com/dote/article/26/4/354/2328831

Esophageal atresia (EA) is a congenital malformation responsible for an esophageal disruption with or without tracheoesophageal fistula (TEF). It occurs in 1/2500 to 1/4000 live births. Several regional, national, or European registries have allowed an epidemiological monitoring of the majority of congenital malformations including EA during the last several years. Prevalence in the era of prenatal diagnosis may change in some countries.

Despite differences in methodology, time, and geography, it seems that the overall prevalence of EA has remained quite stable over the time in the past 3–4 decades world wide, varying from 2.12 per 10 000 live births from 1980 to 1995 (27 registries) to 2.08/10 000 from 1995 to 2009 (43 registries) according to EUROCAT and Swedish studies.1–3 However, regional variations of EA prevalence have been recently demonstrated in Europe within the EUROCAT network, a European organization encompassing regional registries that carry out population-based studies. A recent study demonstrated that the prevalence of EA varied from 1.27 to 4.55 per 10 000 according to different European regions, while the overall prevalence of EA was 2.43 per 10 000 births, which confirmed the stability of EA prevalence over time. The rate of medical termination of pregnancy in fetuses carrying associated malformations in general was 7.8%, but when EA was suspected, this rate increased to 27%.4

The National Birth Defects Prevention Network (NBDPN) was created in 1997 by the Center for Disease Control and Prevention (CDC) in the USA. The data originates from 45 programs of birth monitoring in 30 states. The NBDP Study is an observational study, population based and case controlled, of women having become pregnant in the USA. Ten large cities are included in this network, and the prevalence of EA was calculated from the data of 32 registries from 2003 to 2007. As in Europe, the prevalence was variable according to the regions, from 0.96 to 4.53 per 10 000 births.5

The French national EA registry was created in 2008 by the reference center for congenital abnormalities of the esophagus. It differs from other national registries because it is specific for EA. Its goal is to evaluate the prevalence of this congenital malformation in the children born alive in France and their evolution during infancy. It also collects prenatal data, neonatal treatment and early outcome, as well as follow-up for the first year of life. It is based on a national network of all 38 French centers performing neonatal surgery. The prevalence of EA in 2008 and 2009 in France was 1.97 per 10 000 live births (Table 1). Associated malformations were present in 53% of the cases and survival was 95%. Mortality was higher in premature and small birthweight infants but not among patients carrying associated malformations. EA with TEF was the most frequent type representing 87% of the cases. Survival in this group was not significantly different from pure EA. Prenatal diagnosis was made in 30% of EATEF infants, but was 100% in cases of pure EA. The length of hospitalization and full oral feeding at first discharge were used to evaluate initial morbidity of EA.

Pregnancy test

• add clarification of devices used for hcg blood and urine test - venus

up to date Clinical manifestations and diagnosis of early pregnancy Diagnosis:

• Types of pregnancy tests — Pregnancy tests can be performed on urine or serum. Factors that influence the choice of a urine or serum pregnancy test include duration of missed menses, need for accuracy, convenience, and cost. Tests on urine are adequate for diagnosis of a suspected pregnancy in women who have missed a menstrual period, especially when there is time to follow an initial negative test with a second test a week later. Because urine tests do not detect very low levels of hCG that would be detected by a serum test, a urine test may be negative and the serum test positive around the time of missed menses; therefore, serum tests are preferable when the patient's menstrual period is less than a week late, especially when exclusion of pregnancy is an important factor in patient care, such as before administering a potentially teratogenic agent.
• Serum pregnancy test — In clinical practice, the most sensitive method for detecting hCG in early pregnancy is a serum pregnancy test. Serum pregnancy tests typically detect hCG levels as low as 1 to 2 milli-international units/mL; a "negative" pregnancy test is reported as hCG <1 milli-international unit/mL. By contrast, urine pregnancy tests are less sensitive, detecting hCG beginning at a level of 20 to 50 milli-international units/mL. In addition, the median hCG concentration is higher in serum than in urine [20,41]. Therefore, very early in pregnancy, a serum pregnancy test may be positive while the urine pregnancy test is still negative.
  • The only potential advantage of a qualitative serum pregnancy test over a quantitative test is that the qualitative test can usually be performed more rapidly [42]. The quantitative test procedure requires use of dedicated automated measurement equipment and may be processed only in a commercial or hospital-based laboratory. It takes approximately 15 minutes to complete a test, but because samples are typically processed in batches, it may take much longer to obtain a result.
  • When a quantitative serum test is performed, most women with singleton pregnancies will have a peak value <100,000 milli-international units/mL. Therefore, if a higher hCG level is noted, an ultrasound examination is indicated to exclude a multiple gestation or gestational trophoblastic disease, which could account for the finding.
• Urine pregnancy test — Urine pregnancy testing is the most common method for diagnosing pregnancy. A variety of affordable and reliable qualitative urine tests are available and take only one to five minutes to perform.
  • Standard urine pregnancy tests used in clinical practice have a urine hCG threshold of 20 to 50 milli-international units/mL. Because the urine hCG concentration can be much lower than in serum and urine tests require a higher hCG level to detect the hormone, urine pregnancy tests may not be positive when the serum pregnancy test is positive [43]. At eight days postconception, the serum hCG concentration may be 10 milli-international units/mL, whereas urine hCG concentration may still be less than 1 milli-international unit/mL [23,44,45].
  • A random urine sample can be used for testing because hCG production is not circadian [46-48] and a low urine-specific gravity does not appear to alter the sensitivity of detecting hCG unless the test used has a high threshold for hCG positivity [49,50] or the urine specimen is extremely dilute.
  • A semiquantitative multilevel urine pregnancy test has been developed that measures hCG levels in concentrations of <25, 25 to 99, 100 to 499, 500 to 1999, 2000 to 9999, and >10,000 milli-international units/mL. It is not more useful than a standard urine qualitative test for routine diagnosis of pregnancy. It was developed primarily for follow-up of women after first-trimester medication abortion and monitoring after treatment for ectopic pregnancy.

• Home pregnancy test — Home pregnancy tests (HPTs) are generally highly accurate, but positive results should be confirmed, such as with Doppler confirmation of fetal cardiac activity, sonographic visualization of the pregnancy, and enlarged uterus on physical examination, or a serum or urine hCG test performed by a clinician.
  • Women choose to use HPT kits because of the speed of obtaining results and the convenience of testing at home. Many brands of HPT kits are available. They detect hCG in the urine using immunometric assay methods [12]. The performance of HPTs is affected by the users' technique and interpretation [45,51]. These tests are interpreted by noting the number of color bands/lines in the window of the device a few minutes after dipping it in urine for several seconds. A positive test will show two band/lines (eg, "ll" or "+"), while a negative test only shows one band/line (eg, "l" or "-"). Some devices have a digital display that shows "yes" or "no" or "pregnant" or "not pregnant" on an LCD screen.
  • Although manufacturers claim these kits are 99 percent accurate, this claim is based upon the ability of the test to detect an arbitrary amount of intact hCG added to nonpregnant urine samples in vitro. In many cases, it will not be sensitive enough to diagnose pregnancy in women who have recently missed a menstrual period.
  • The most common problem with HPT kits is a "false" negative result because the test was performed too soon after the expected onset of menses. The intervals between the first day of the LMP, ovulation, fertilization, implantation, and production of sufficient hCG for detection by an HPT are variable. If pregnancy is suspected despite a negative test, the test should be repeated in one week. Many HPT kits make this recommendation and provide an extra kit for this purpose
  • Practitioners can use the following data to advise their patients on selection of HPT kits and their limitations. HPT kits vary in sensitivity for detection of hCG; some do not detect levels below 100 milli-international units/mL [45,52]. This variability was demonstrated by a blinded in vitro sensitivity analysis of six commonly used HPT kits that found the following [53]:
    • First Response manual and First Response Gold digital devices were the most sensitive HPT kits with analytical sensitivity 5.5 milli-international units/mL. Over 97 percent of pregnancies could be detected on the first day of a missed period.
    • The next tier of tests had analytical sensitivity 11 to 22 milli-international units/mL.
    • EPT manual and digital devices detected 54 and 67 percent of pregnancies, respectively, on the first day of a missed period.
    • Clearblue Easy manual and digital devices detected 64 and 54 percent of pregnancies, respectively, on the first day of a missed period

The hCG Immunoassay Readings on Pregnancy Test