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Objective: This study aimed to survey the practice of palliative sedation in Portugal, where data on this subject were lacking. Methods: This was a prospective multicentric study that included all patients admitted to each team that agreed to participate. Patients were followed until death, discharge, or after 3 months of follow-up. Results: The study included 8 teams: 4 as palliative care units (PCU), 1 as a hospital palliative care team (HPCT), 2 as home care (HC), and 1 as HPCT and HC. Of the 361 patients enrolled, 52% were male, the median age was 76 years, and 285 (79%) had cancer. Continuous sedation was undergone by 49 (14%) patients: 26 (53%) were male, and the median age was 76. Most patients, 46 (94%), had an oncological diagnosis. Only in a minority of cases, the family, 16 (33%), or the patient, 5 (10%), participated in the decision to sedate. Delirium was the most frequent symptom leading to sedation. The medication most used was midazolam (65%). In the multivariable analysis, only age and the combined score were independently associated with sedation; patients <76 years and those with higher levels of suffering had a higher probability of being sedated. Conclusions: The practice of continuous palliative sedation in Portugal is within the range reported in other studies. One particularly relevant point was the low participation of patients and their families in the decision-making process. Each team must have a deep discussion on this aspect. [ABSTRACT FROM AUTHOR]

Background: Palliative Sedation (PS) at the end of life is practiced and perceived differently by health professionals depending on the geographical location in which they provide their health care. Taking into account this heterogeneity, it is necessary to expand knowledge and provide data on this clinical practice in different contexts and countries. On the other hand, the identification of factors associated with PS could help healthcare professionals, at an early stage, to identify patients more likely to require sedation. The aim of this study was to describe the prevalence and characteristics related to PS in a specialised Palliative Care setting, as well as to analyse factors that could be associated with this procedure. Methods: This was a cross-sectional study including n = 533 patients who died during the study period in a Palliative Care Unit. Clinical and functional (Barthel and Palliative Performance Scale) variables and the level of complexity were collected. For each patient we assessed whether PS had been performed and, if so, we described the type of sedation, continuity and depth, refractory symptoms, medication used, informed consent and place of death. A multivariate logistic regression model was used to analyse the relationship between several independent variables and PS. Results: The prevalence of PS was 16.7% (n = 82). Most frequent refractory symptoms were delirium (36.1%), pain (31.9%) and dyspnoea (25%). Factors associated with having a higher odds of PS were having already started treatment with strong opioids (OR = 2.10; 95% CI = 1.16–3.90) and a lower dependency for activities of daily living (OR = 0.41; 95% CI = 0.23–0.70) on admission at PC. Informed consent for sedation was given mainly by representation and only in 19% of cases by the patient himself. Conclusions: Early opioid use and functional status act as factors associated with PS, becoming as clinical evaluations of particular interest during the disease trajectory, which could help to improve individualised care plans for patients at the end of life. [ABSTRACT FROM AUTHOR]

Aim: To analyse the available evidence regarding refractory symptoms to treatment in patients receiving palliative/terminal healthcare. Design: A systematic review of various databases between September and December 2020; Pubmed; Cochrane; Scopus and ScienceDirect. Study eligibility criteria: Studies published between 1st January 2015 and 31st of March 2020, in Spanish, English or Catalan conducted in elderly people or terminal patients. The study included systematic reviews, clinical trials and interventions. Results: The search returned 782 articles, of which 22 articles were finally reviewed. Of the selected articles, 16 were systematic reviews and three were clinical trials. Three refractory symptoms are notable; breathlessness, delirium and existential suffering. There are various therapeutic approaches for the first two symptoms, but palliative sedation seems to be most effective for existential suffering. Conclusions: Although palliative care enables controlling these symptoms effectively, and following a multidisciplinary approach, there remains a group of patients for whom euthanasia could save foreseeable suffering that is difficult to manage. [ABSTRACT FROM AUTHOR]

Abstract Background Patients at the end-of-life may experience refractory symptoms of which pain, delirium, vomiting and dyspnea are the most frequent. Palliative sedation can be considered a last resort option to alleviate one or more refractory symptoms. There are only a limited number of (qualitative) studies exploring the experiences of relatives of sedated patients and their health care professionals (HCPs). The aims of this study protocol are: 1) to elicit the experiences of bereaved relatives and health care professionals of patients treated with palliative sedation and 2) to explore the understanding of the decision-making process to start palliative sedation across care settings in 5 European countries. Methods This study protocol is part of the larger HORIZON 2020 Palliative Sedation project. Organisational case study methodology will be used to guide the study design. In total, 50 cases will be conducted in five European countries (10 per country). A case involves a semi-structured interview with a relative and an HCP closely involved in the care of a deceased patient who received some type of palliative sedation at the end-of-life. Relatives and health care professionals of deceased patients participating in a linked observational cohort study of sedated patients cared for in hospital wards, palliative care units and hospices will be recruited. The data will be analyzed using a framework analysis approach. The first full case will be analyzed by all researchers after being translated into English using a pre-prepared code book. Afterwards, bimonthly meetings will be organized to coordinate the data analysis. Discussion The study aims to have a better understanding of the experiences of relatives and professional caregivers regarding palliative sedation and this within different settings and countries. Some limitations are: 1) the sensitivity of the topic may deter some relatives from participation, 2) since the data collection and analysis will be performed by at least 5 different researchers in 5 countries, some differences may occur which possibly makes it difficult to compare cases, but using a rigorous methodology will minimize this risk.

There is a lack of report of conscious sedation used as a last resort therapy for alleviating severe symptoms. To achieve this goal, dexmedetomidine appears to be a promising option. We report a case of successful two-month long treatment of intravenous (IV) dexmedetomidine added to hydromorphone for intractable cancer pain, restlessness, severe sleep disorder, anxiety, and craving symptoms in a 40-year-old man with active polysubstance use, receiving escalating doses of opioids for intractable abdominal cancer pain together with benzodiazepines. Under dexmedetomidine infusion at 1.2 μg/kg/hour, his symptoms markedly decreased. He could sleep at night and find respite during the day while continuing walking, eating, and other activities. Long-term conscious sedation with IV dexmedetomidine was well tolerated. We did not observe anxiety or agitation rebound during short periods of discontinuation of the infusion. Neither side effects nor tolerance were observed over time. Further research is needed to investigate the indications for conscious sedation and analgesia with dexmedetomidine in palliative patients with a prognosis that is longer than few weeks or uncertain. [ABSTRACT FROM AUTHOR]

Background: Patients at the end-of-life may experience refractory symptoms of which pain, delirium, vomiting and dyspnea are the most frequent. Palliative sedation can be considered a last resort option to alleviate one or more refractory symptoms. There are only a limited number of (qualitative) studies exploring the experiences of relatives of sedated patients and their health care professionals (HCPs). The aims of this study protocol are: 1) to elicit the experiences of bereaved relatives and health care professionals of patients treated with palliative sedation and 2) to explore the understanding of the decision-making process to start palliative sedation across care settings in 5 European countries. Methods: This study protocol is part of the larger HORIZON 2020 Palliative Sedation project. Organisational case study methodology will be used to guide the study design. In total, 50 cases will be conducted in five European countries (10 per country). A case involves a semi-structured interview with a relative and an HCP closely involved in the care of a deceased patient who received some type of palliative sedation at the end-of-life. Relatives and health care professionals of deceased patients participating in a linked observational cohort study of sedated patients cared for in hospital wards, palliative care units and hospices will be recruited. The data will be analyzed using a framework analysis approach. The first full case will be analyzed by all researchers after being translated into English using a pre-prepared code book. Afterwards, bimonthly meetings will be organized to coordinate the data analysis. Discussion: The study aims to have a better understanding of the experiences of relatives and professional caregivers regarding palliative sedation and this within different settings and countries. Some limitations are: 1) the sensitivity of the topic may deter some relatives from participation, 2) since the data collection and analysis will be performed by at least 5 different researchers in 5 countries, some differences may occur which possibly makes it difficult to compare cases, but using a rigorous methodology will minimize this risk. [ABSTRACT FROM AUTHOR]

Although palliative sedation (PS) is a common practice in the palliative care of cancer patients in Western countries, there is little related research on the practice in Korea. PS can be classified into several categories according to sedation level and continuity. PS is clearly distinct from euthanasia. While euthanasia is illegal and regarded as unethical in Korea, there is little ethical and legal controversy about PS in terms of the doctrine of double effect. Most studies have asserted that PS does not shorten the survival of terminal cancer patients. Since preference for PS heavily depends on stakeholder value, it should be preceded by shared decision-making through full communication among the patient, family members, and medical team. This is a narrative review article analyzing previous studies, especially from the three Eastern Asian countries, Korea, Japan and Taiwan, which share similar cultures compared with Western countries. Practical issues concerning PS—for example, prevalence, type and dosage of medications, salvage medication, timing of its initiation, and assessment—are described in detail. [ABSTRACT FROM AUTHOR]

Purpose: Palliative sedation (PS) plays a critical role to give suffering relief from refractory symptoms at the end of life. Our audit aimed to assess and improve quality of PS at the Department of Oncology and Hematology of University Hospital of Modena, to verify the adherence to international guidelines, the cooperation among members of care team, focusing with attention on family's perception of this delicate situation.Methods: From December 2016 to June 2019, data of patients undergoing PS in the Department were collected by an electronic folder tool, "Sedation Tool" (ST), that recorded clinical and PS informations, D-PaP, Rudkin score, and family's perception.Results: In total, 245 patients were enrolled. Eighty-two percent had a Karnofsky Performance Status 10-20%. The most common cancer types were lung and gastro-intestinal carcinomas (27% and 21% respectively). Refractory symptoms observed were confusion and agitation (76%), dyspnea (39%), pain (15%), delirium (10%), and psychological distress (5%). Midazolam was the drug of choice for PS. Most of patients had Rudkin score 5 after 24 h and 33% had terminal event within a period of 24 h from the beginning of PS. During PS, most of patient's relatives reported peacefulness (65%), agitation/impatience in 6% of cases, and concern for suffering (16%).Conclusion: PS is used in case of worsening general conditions at the end-stage disease to relieve refractory symptoms with dignity. The ST can become a simple instrument to evaluate and improve PS quality, providing more attention on the impact of PS on relatives to then possibly develop new supportive procedures for patients and their families. [ABSTRACT FROM AUTHOR]

Purpose of the review to present up-to-date data on the causes, methods of diagnosis and treatment of the refractory form of gastroesophageal reflux disease (GERD). Refractory GERD is the preservation of typical symptoms of the disease and/or incomplete healing of the esophageal mucosa against the background of taking a standard dose of proton pump inhibitors (PPI) once a day for 8 weeks. The reasons for the lack of response to the treatment are divided into related to the patient, related to therapy, and not related to GERD. Diagnostic approaches include x-ray examination of the esophagus and stomach, endoscopy with biopsy, 24-hour Impedance-pH monitoring, esophageal manometry. Depending on the reasons for the lack of response to the therapy, treatment may include lifestyle changes, doubling the dose of PPI, replacing PPI with another, adding H2-receptor antagonists, prokinetics, antacids, alginates and adsorbents. If conservative treatment is ineffective, it is possible to consider alternative methods, such as surgical treatment. Refractory GERD is a serious clinical problem. The absence of an answer to 8-week therapy with PPI requires a thorough differential diagnosis using additional examination methods. The identification of the causes of refractory to the therapy allows to optimize the approaches to its overcoming and to choose the optimal treatment.

Summary: Delirium is a frequent neurocognitive complication in cancer patients, particularly in advanced stage and terminal disease. It is associated with increased morbidity and mortality and is a critical source of stress for patients and caregivers. For healthcare staff, delirium poses significant challenges in diagnosis and treatment as well as assessment of other symptoms due to its fluctuating nature, communication impediments, and possible agitation in hyperactive subtypes. Pathophysiological mechanisms underlying delirium are complex, but the approach to adequate symptom management consists of nonpharmacological strategies as well as the use of antipsychotic agents. However, when nonreversible and refractory delirium occurs, palliative sedation is an invaluable treatment option and may be offered after careful consideration. This short review attempts to cover important aspects of clinical features of delirium, diagnostic and treatment strategies as well as the role of palliative sedation in refractory situations in delirious cancer patients at the end of life. [ABSTRACT FROM AUTHOR]

Highlights • The PSTD psychosocial treatment literature does not often examine residual symptoms. • We examined residual PTSD and secondary symptoms in RCTs of empirically supported treatments. • Most studies had evidence of at least subthreshold residual PTSD symptoms. • Two thirds of studies had residual symptoms of associated comorbidities. Abstract Objective Although residual symptoms remain following clinical treatment for posttraumatic stress disorder (PTSD), little is known about the characteristics of these residual symptoms. We aimed to determine the type, severity, and frequency of symptoms that remain after trauma-focused psychotherapy. Methods We conducted a systematic review of 51 randomized controlled trials of empirically supported psychosocial interventions for PTSD (68 total treatment arms). Outcomes included: 1) PTSD symptoms and 2) conditions commonly comorbid with PTSD: depression, anxiety, and quality of life impairment. Results In general, the results revealed that participants who completed PTSD treatment continued to report residual PTSD symptoms: 31% reported clinical symptom levels, and 59% reported subthreshold levels at posttreatment, particularly within the hyperarousal cluster. Residual symptoms also emerged for depression (19% clinical), anxiety (55% clinical), and quality of life (36% clinical). Few differences emerged across treatment types, but differential patterns were revealed for sample/trauma types. Conclusions Results suggest a need for focused research attention to and clinical assessment of individual residual symptoms following empirically supported treatment for PTSD to determine whether further treatment sessions are warranted. [ABSTRACT FROM AUTHOR]

Substantial evidence supports the use of either clozapine or cognitive-behaviour therapy (CBT) for refractory symptoms of psychosis, and are recommended in many national guidelines. However, the two treatments have not been directly compared in a head-to-head trial. The aim of this study is to estimate the proportion of clients with refractory symptoms of psychosis who might benefit from either treatment. We reviewed the charts of 137 clients, consecutively referred to a speciality clinic for refractory psychosis, against inclusion and exclusion criteria for both clozapine and CBT. The results indicate that approximately one-third of patients referred for either CBT or clozapine would simultaneously meet eligibility criteria for both treatments, and would thus be eligible for randomization. If these results are validated in a prospective study, a controlled trial comparing CBT and clozapine for refractory symptoms of psychosis is likely feasible.

Dexmedetomidine, a selective alpha2 agonist, is traditionally used briefly for perioperative anesthesia and sedation of mechanically ventilated patients. Reports of its use in patients with opioid-induced hyperalgesia1 and intractable pain and delirium2 suggested it for patients who otherwise may have required palliative sedation to relieve suffering. We present the protocol developed by the interdisciplinary team in our intensive palliative care unit that allows for safe titrated administration without required vital sign monitoring outside the intensive care unit (ICU) (Supplementary Appendix SA1). We describe its efficacy in eight patients who were receiving comfort-focused care. [ABSTRACT FROM AUTHOR]

Respect for human life is central to medicine. In terminal patients, refractory symptoms are a niche of palliative sedation. This paper identifies, based on scientific evidence, the survival in patients who received palliative sedation as compared to those who didn’t. We conducted a search for systematic reviews from 2000 to 2016, which were methodologically analyzed, and the results were then compared. For methodological reasons, meta-analysis could not be performed. It is concluded that terminal palliative sedation does not shorten patients’ lives. The implementation of the principle of double effect related to the possible shortening of life was reformulated; the unwanted evil is the loss of consciousness. [ABSTRACT FROM AUTHOR]

Continuous deep sedation at the end of life is a specific form of palliative sedation requiring a care plan that essentially places and maintains the patient in an unresponsive state because their symptoms are refractory to any other interventions. Because this application is uncommon, many providers may lack practical experience in this specialized area and resources they can access are outdated, nonspecific, and/or not comprehensive. The purpose of this review is to provide an evidence- and experience-based reference that specifically addresses those medications and regimens and their practical applications for this very narrow, but vital, aspect of hospice care. Patient goals in a hospital and hospice environments are different, so the manner in which widely used sedatives are dosed and applied can differ greatly as well. Parameters applied in end-of-life care that are based on experience and a thorough understanding of the pharmacology of those medications will differ from those applied in an intensive care unit or other medical environments. By recognizing these different goals and applying well-founded regimens geared specifically for end-of-life sedation, we can address our patients' symptoms in a more timely and efficacious manner. [ABSTRACT FROM AUTHOR]

Objective: Cultural, social, and legal factors have been known to affect physicians' practice of continuous deep sedation. There have been few quantitative studies to compare continuous deep sedation practice in Asian countries. We aimed to describe and compare clinical characteristics of continuous deep sedation in Japan, Korea and Taiwan., Methods: Patients with advanced cancer admitted to participating palliative care units were enrolled from January 2017 to September 2018. We evaluated and compared (i) the prevalence of continuous deep sedation, (ii) the characteristics of sedated and non-sedated groups in each country, and (iii) continuous deep sedation administration patterns among the three countries., Results: A total of 2158 participants were included in our analysis, and 264 received continuous deep sedation. The continuous deep sedation prevalence was 10, 16 and 22% in Japan, Korea and Taiwan, respectively. Delirium was the most frequent target symptom in all countries, along with dyspnoea (in Japan) and psychological symptoms (in Korea). Midazolam was most frequently used in Japan and Taiwan, but not in Korea (P < 0.001). Among the patients receiving continuous deep sedation, the hydration amount on the final day was significantly different, with median volumes of 200, 500 and 0 mL in Japan, Korea and Taiwan, respectively (P < 0.001). In Korea, 33% of the continuous deep sedation administration caused a high degree of physicians' discomfort, but 3% in Japan and 5% in Taiwan (P < 0.001)., Conclusions: Clinical practices of continuous deep sedation and physicians' discomfort related to continuous deep sedation initiation highly varied across countries. We need to develop optimal decision-making models of continuous deep sedation and hydration during continuous deep sedation in each country., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

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Context: Knowledge of determinants that are associated with the administration of continuous palliative sedation (CPS) helps physicians identify patients who are at risk of developing refractory symptoms, thereby enabling proactive care planning.Objectives: This study aims to explore which patient-related factors at admission are associated with receiving CPS later in the terminal phase of life.Methods: A prospective multicenter observational study was performed in six Dutch hospices and three nursing home-based palliative care units. The association between patient-related variables at admission (age, gender, diagnosis, use of opioids or psycholeptics, number of medications, Karnofsky Performance Status scale score, Edmonton Symptom Assessment System distress score, and Glasgow Coma Scale score) and the administration of CPS at the end of life was analyzed.Results: A total of 467 patients died during the study period, of whom 130 received CPS. In univariate analysis, statistically significant differences were noted between the sedated and nonsedated patients with respect to younger age (P = 0.009), malignancy as a diagnosis (P = 0.05), higher Karnofsky Performance Status score (P = 0.03), the use of opioids (P < 0.001), the use of psycholeptics (P = 0.003), and higher Edmonton Symptom Assessment System distress score (P = 0.05). Multivariate logistic regression analysis showed that only the use of opioids at admission (odds ratio 1.90; 95% confidence interval 1.18-3.05) was significantly associated with the administration of CPS.Conclusion: Physicians should be aware that patients who use opioids at admission have an increased risk for the administration of CPS at the end of life. In this group of patients, a comprehensive personalized care plan starting at admission is mandatory to try to prevent the development of refractory symptoms. Further research is recommended, to identify other determinants of the administration of CPS and to investigate which early interventions will be effective to prevent the need for CPS in patients at high risk. [ABSTRACT FROM AUTHOR]

Phenobarbital is used in hospice and palliative care to treat refractory symptoms. In end-of-life care, Food and Drug Administration approved routes of administration may be unreasonable based on patients’ status. In these cases, phenobarbital may be administered subcutaneously for symptom management. However, according to the American Hospital Formulary Service, subcutaneous administration of commercially available injectable phenobarbital is cautioned due to possible skin reactions. This study evaluates the tolerability of phenobarbital administered subcutaneously. Of 69 patients and 774 distinct subcutaneous phenobarbital injections, 2 site reactions were recorded (2.9% of patients; 0.3% of injections). Both were mild, grade 1 reactions. Each patient continued to receive subcutaneous phenobarbital via newly placed ports with no additional reactions. Based on these findings, phenobarbital appears to be well tolerated when administered subcutaneously. [ABSTRACT FROM AUTHOR]

In Belgium, continuous sedation in palliative care is considered a symptomatic treatment. There is no specific legislation to govern it. Its proper use is based on a set of recommendations that ensure both effective treatment and respect for the patient's preferences, within a rigorous ethical framework., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

The practice of palliative sedation (PS) at the end of life has been examined and debated increasingly in ethical and clinical literature. The "argument of preferable alternative" (APA), first brought up by Justice O'Connor in her judgement in Washington v Glucksberg in 1997, has been examined and used by Raus et al in the argument for the application of PS in place of physician-assisted suicide (PAS) By examining the concepts and terminology in PS from both individual and collective views within different guidelines and the assumptions of APA, we suggest that PS is too variable in practice to harness the APA. [ABSTRACT FROM AUTHOR]

The article cites a study which examines reported practice of Great Britain, Belgian and Dutch physicians and nurses. The study data was collected using qualitative case studies through interviews. British respondents reported a continuum of practice from the provision of low doses of sedatives to control terminal restlessness to rarely encountered deep sedation.

'Refractory gastroesophageal reflux disease' is one of the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive proton pump inhibitor therapy. The term should be replaced with 'refractory symptoms.' We must acknowledge that in many patients symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to diagnostic testing. In majority of patients these tests are normal. The role of non-acid reflux in this group is uncertain and patients should not undergo surgical fundoplication based on this parameter. In patients unresponsive to acid suppressive therapy GERD is most commonly not causal and a search for non-GERD causes must ensue. [ABSTRACT FROM AUTHOR]

Background: Nighttime acid reflux that influences refractory symptoms is strongly associated with sleep disturbances. The aim of this study was to examine the associations between sleep disturbances and refractory gastroesophageal reflux disease (GERD) symptoms in patients receiving once daily proton pump inhibitors (PPI) and the efficacy of twice-daily rabeprazole treatment. Method: In a multicenter survey, 433 GERD patients receiving once-daily PPI treatment completed a self-report questionnaire that included the Frequency Scale for the Symptoms of GERD (FSSG) and questions about sleep disturbances. Study cases were defined as patients with an FSSG score ≥8. Of the 222 study cases, 106 individuals received rabeprazole 10 mg twice daily for 4-8 weeks. Results: Of the 433 subjects, 222 patients revealed FSSG scores of ≥8. Use of a half dose of PPI was associated with such cases. PPI-refractory symptoms were found in 46% of patients with standard-dose PPI treatment. Nighttime symptoms (OR = 2.56), daytime sleepiness (OR = 1.64), and poorer sleep quality (OR = 1.67) were significantly associated with refractory GERD symptoms. Twice-daily rabeprazole treatment significantly improved FSSG scores and sleep disturbances. Conclusion: About half of the GERD patients receiving once-daily standard-dose PPI treatment had refractory GERD symptoms. Sleep disturbances were significantly associated with refractory GERD symptoms. Twice-daily rabeprazole treatment was effective in such cases. Copyright © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: A retrospective study evaluated safety, symptom resolution, patient satisfaction, and medication use 1-2 years after transoral incisionless fundoplication (TIF) in patients with gastroesophageal reflux disease (GERD) and/or laryngopharyngeal reflux (LPR) symptoms. Methods: Thirty-four patients with a confirmed diagnosis of GERD symptoms that were inadequately controlled by antisecretory medications, and who where either dissatisfied with their current therapy or not willing to continue taking medication, underwent TIF using EsophyX at our community-based hospital. Follow-up assessments were completed in 28 patients. Results: Median age of the study group was 57 (range = 23-77) years, BMI was 25.7 (18.3-36.4) kg/m, and 50% were female. All patients had documented chronic GERD for a median 5 (1-20) years and refractory symptoms to proton pump inhibitors (PPIs). Hiatal hernia was present in 75% (21/28) of patients, and 21% (6/28) had erosive esophagitis (LA grade A or B). TIF was performed following a standardized TIF-2 protocol and resulted in reducing hiatal hernia and restoring the natural anatomy of the gastroesophageal (GE) junction (Hill grade I). There were no postoperative complications. At a median 14-months follow-up, 82% (23/28) of patients were off daily PPIs (64% completely off PPIs), and 68% (19/28) were satisfied with their current health condition compared to 4% before TIF. Median GERD Health-Related Quality of Life scores were significantly reduced to 4 (0-25) from 26 (0-45) before TIF ( P < 0.001). Heartburn was eliminated in 65% (17/26) and improved by >50% in 86% (24/28) of patients. Regurgitation was eliminated in 80% (16/20) of patients. Atypical LPR symptoms such as hoarseness, coughing, and throat clearing were eliminated in 63% (17/27) of patients as measured by Reflux Symptom Index scores. Conclusion: Our results in 28 patients confirm the safety and effectiveness of TIF, documenting symptomatic improvement of GERD and LPR symptoms and clinically significant discontinuation of daily PPIs in 82% of patients. [ABSTRACT FROM AUTHOR]

The article focuses on a comparative analysis in Europe and Latin America, of using palliative sedation for patients at the end of their lives. The European Association for Pallative Care Forum recommends the non-usage of the term "terminal sedation" for palliative sedation since it is seen more to relieve unbearable suffering. This intention differentiates it from euthanasia which destroys the problem rather than solving it. Latin Ameica and Europe have similar ethical positioning of norms.

This retrospective study evaluated clinical outcomes in 124 consecutive gastroesophageal reflux disease (GERD) patients who underwent transoral incisionless fundoplication (TIF) at 2 community hospitals. Out of 123 patients treated successfully, 110 gave consent (74% female, median age 60 [range 21-87] years, body mass index 27.5 [19.0-47.9]). At a median 7-month follow-up (range 5-17), typical and atypical symptom scores were normalized in 75% to 80% of patients, proton pump inhibitors (PPIs) were completely discontinued by 93%, and 83% were satisfied with their current health condition. Endoscopy in 53 patients revealed Hill grade I tight valves in 89% of the cases, reduced hiatal hernia in 33/34 (97%), and healed reflux esophagitis in 25/30 (83%). Based on global analysis, 72% of the patients were in remission, 20% improved symptomatically, and only 8% had ongoing GERD. These results supported the safety and efficacy of TIF as well as encouraged its application as an alternative treatment of GERD refractory to PPIs. [ABSTRACT FROM PUBLISHER]

Goals The goal of this study is to evaluate the feasibility and efficacy of palliative sedation at home (PSH) to approach refractory symptoms in dying cancer patients. Materials and methods Charts of 121 patients, observed by "L'Aquila per la Vita" Home Care Unit, from August 2006 to May 2008, were reviewed. Sixteen patients out of 44 who died at home (36.4%) were sedated. Indication for sedation was agitated delirium in 13 patients and dyspnea in three patients. A multistep midazolam-based protocol was administered. Results In all patients, a deep, prolonged, continuous sedation was obtained. No treatment-related complications were registered. Conclusion A midazolam-based protocol for PSH is feasible and effective. Our results need to be confirmed by prospective, multicentric, controlled studies. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to explore determinants of residual reflux symptoms among patients with gastroesophageal reflux disease (GERD) despite maintenance treatment with acid suppressive medication (ASM). Methods: Primary care GERD patients on chronic ASM were classified as symptom-free (55%) or symptomatic (45%) according to the impact of their residual reflux symptoms (QolRad). They were compared with respect to lifestyle (BMI, alcohol, smoking, physical exercise), compliance (daily ASM dosage), disease history, psychological factors (SCL-90) and quality of life (SF-36). Results: None of the investigated lifestyle factors, nor dosage and disease history were related to residual symptoms. However, symptomatic patients differed from patients with relief on all psychological and quality of life dimensions. In a multiple logistic regression model somatization, hostility, mental health, body pain, as well as gender were independently associated with residual symptoms; the derived ROC curve had an AUC of 0.78. Conclusions: The majority of GERD patients is symptom-free on chronic ASM; they display a healthy psychological state and high quality of life. Residual symptoms however, are associated with psychological distress and lower quality of life. Recognition of this subgroup might hold the key to improving long-term management of gastroesophageal reflux. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Copyright of Der Urologe A is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Of 1200 palliative care patients, 28 received palliative sedation. They were more likely than patients without palliative sedation to have an Eastern Cooperative Oncology Group performance status of at least 3, a cancer diagnosis, an expected survival of weeks or less, to have been monitored by the palliative care team for at least 1 week, to have delirium as the cause of decreased communication, to have dyspnea as a non-pain symptom, and to be less able to communicate symptoms. Almost 90% received palliative sedation for at least 24 hours for a median of 3 days (range, 0 to 24 days). Home patients received palliative sedation longer. Symptoms were controlled in 82% and improved in the rest. Sedation developed in 79% but was not required for symptom control in 5. Patient survival from palliative care consultation was a median of 8 days (range, 0 to 32 days). [ABSTRACT FROM AUTHOR]

Abstract: Although palliative sedation therapy is often required in terminally ill cancer patients to achieve acceptable symptom relief, empirical data supporting the ethical validity of this approach are lacking. The primary aim of this study was to systematically investigate whether empirical evidence supports the ethical validity of sedation. This was a multicenter, prospective, observational study, which was conducted by 21 specialized palliative care units in Japan. One-hundred two consecutive adult cancer patients who received continuous deep sedation were enrolled. Continuous deep sedation was defined as the continuous use of sedative medications to relieve intolerable and refractory distress by achieving almost or complete unconsciousness until death. Prior to the study, we conceptualized the ethical validity of sedation from the viewpoints of physicians'' intent, proportionality, and autonomy. Sedation was performed mainly with midazolam and phenobarbital. The initial doses of midazolam and phenobarbital were 1.5 mg/hour and 20 mg/hour, respectively. Main administration routes were continuous subcutaneous infusion and continuous intravenous infusion, and no rapid intravenous injection was reported. Of 59 patients who received artificial hydration or could intake adequate fluids/foods orally before sedation, 63% received artificial hydration therapy after sedation, and in the remaining patients, artificial hydration was withheld or withdrawn due to fluid retention symptoms and/or patient wishes. Of 66 patients who were able to verbally express themselves, 95% explicitly stated that symptoms were intolerable. The etiologies of the symptoms requiring sedation were primarily related to the progression of the underlying malignancy, such as cancer cachexia and organ failure, and standard palliative treatments had failed: steroids in 68% of patients with fatigue, opioids in 95% of patients with dyspnea, antisecretion medications in 75% of patients with bronchial secretion, antipsychotic medications in 74% of patients with delirium, and opioids in all patients with pain. On the basis of the Palliative Prognostic Index, 94% of the patients were predicted to die within 3 weeks. Before sedation, 67% of the patients expressed explicit wishes for sedation. In the remaining 34 patients, previous wishes for sedation were noted in 4 patients, and in the other 30 patients, the families were involved in the decision-making process. The chief reason for patient non-involvement in the decision making was cognitive impairment. These data indicate that palliative sedation therapy performed in specialized palliative care units in Japan generally followed the principles of double effect, proportionality, and autonomy. [Copyright &y& Elsevier]

Abstract: Although palliative sedation therapy is often required in terminally ill cancer patients, its efficacy and safety are not sufficiently understood. The primary aims of this multicenter observational study were to 1) explore the efficacy and safety of palliative sedation therapy, and 2) identify the factors contributing to inadequate symptom relief and complications, using a prospective study design, clearly defined measurement methods, and a consecutive sample from 21 specialized palliative care units in Japan. A sample of 102 consecutive adult cancer patients who received continuous deep sedation were enrolled. Physicians prospectively evaluated the intensity of patient symptoms, communication capacity, respiratory rate, and complications related to sedation. Symptoms were measured on the Agitation Distress Scale, the Memorial Delirium Assessment Scale, and the ad hoc symptom severity scale (0 = no symptoms, 1 = mild and tolerable symptoms, 2 = intolerable symptoms for less than 15 minutes in the previous one hour, and 3 = intolerable symptoms continuing for more than 15 minutes in the previous one hour). Inadequate symptom relief was defined as presence of hyperactive delirium (item 9 of the Memorial Delirium Assessment Scale ≥2) or grade 2 or 3 symptom intensity 4 hours after sedation. The degree of communication capacity was measured on the Communication Capacity Scale. Palliative sedation therapy succeeded in symptom alleviation in 83% of the cases. Median time elapsed before patients initially had one continuous hour of deep sedation was 60 minutes, but 49% of the patients awakened once after falling into a deeply sedated state. The percentage of patients who were capable of explicit communication decreased from 40% before sedation to 7.1% 4 hours after sedation, and the mean Communication Capacity Score significantly decreased to the level of 15 points (P < 0.001). The respiratory rates did not significantly decrease after sedation (18 ± 9.0 to 16 ± 9.4/min, P = 0.62), but respiratory and/or circulatory suppression (respiratory rate ≤ 8/min, systolic blood pressure ≤ 60mHg, or 50% or more reduction) occurred in 20%, with fatal outcomes in 3.9%. There were no statistically significant differences in patient age, sex, performance status, target symptoms, or classes and initial dose of sedative medications between the patients with adequate and inadequate symptom relief. Respiratory and/or circulatory suppression was significantly more likely to occur in patients receiving sedation for delirium and those with higher levels on the Agitation Distress Scale. Higher dose of midazolam was significantly correlated with younger age, absence of icterus, pre-exposure to midazolam, and length of sedation. Palliative sedation therapy is effective and safe in the majority of terminally ill cancer patients with refractory symptoms. However, a small number of patients experience fatal complications related to sedation. Comparison studies of different sedation regimens are needed to determine the most effective and safe sedation protocol. [Copyright &y& Elsevier]

The clinical status of terminal cancer patients is very complex and is affected by several severe symptoms, of extended duration, changing with time and of multifactorial origin. When there are no reasonable cancer treatments specifically able to modify the natural history of the disease, symptom control acquires priority and favours the possible better adaptation to the general inexorable deterioration related to the neoplasic progression. Despite the important advances in Palliative Medicine, symptoms are frequently observed that are intolerable for the patient and which do not respond to usual palliative measures. This situation, characterised by rapid deterioration of the patient, very often heralds, implicitly or explicitly, approaching death. The intolerable nature and being refractory to treatment indicates to the health-care team, on many occasions, the need for sedation of the patient. The requirement for sedation of the cancer patient is a situation that does not allow for an attitude of doubt regarding maintenance of the patient in unnecessary suffering for more than a reasonable time. Given the undoubted clinical difficulty in its indication, it is important to have explored at an earlier stage all usual treatments possible and the grade of response, commensurate with the patient's values and desires. Sedation consists of the deliberate administration of drugs in minimum doses and combinations required not only to reduce the consciousness of the patients but also to achieve adequate alleviation of one or more refractory symptoms, and with the prior consent given by the patient explicitly, or implicitly or delegated. Sedation is accepted as ethically warranted when considering the imperative of palliation and its administration and, whenever contemplated, the arguments that justify them are clear recorded in the clinical history. It is not an easy decision for the physican since, traditionally, the training has been “for the fight to save life”. Nevertheless, it seems necessary to make some preparations regarding these problems that have a central affect on the clinical oncologist in his daily function. [ABSTRACT FROM AUTHOR]

The anesthetic propofol is used in a number of medical applications including surgery, procedural sedation, refractory status epilepticus, alcohol withdrawal, and critical care sedation. The manner in which it is dosed and administered in each environment varies, tailored to the specific task at hand. Because the use of propofol in end-of-life care is uncommon, providers may lack practical experience, and resources that are specific to this specialized application are not comprehensive and largely based on dosing and administration as it is done on the intensive care unit. The purpose of this review is to provide an evidence and experienced based reference for the specific use of propofol for end of life sedation.