Palliative Sedation and Nursing: The Place of Palliative Sedation Within Palliative Nursing Care

Patricia Claessens, RN, MSN; Ellen Genbrugge, RN; Rita Vannuffelen, RN; Bert Broeckaert, PhD; Paul Schotsmans, PhD; Johan Menten, MD, PhD

Disclosures

Journal of Hospice and Palliative Nursing. 2007;9(2):100-106. 

In This Article

Abstract and Introduction

Despite the fact that palliative sedation can be considered a gradually accepted form of therapy within palliative care, it still remains a much debated issue in palliative nursing. Moreover, research shows that palliative sedation often involves an emotional burden for care providers and, more specifically, for nurses. This article focuses on clarifying how palliative sedation as a therapy fits into the care perspective of palliative nursing. It describes the way in which decisions can be made about sedation and how the practical procedure may be carried out, and it illustrates the role the nurse can play. It becomes clear that nurses, alongside other care providers, play a crucial role in the process of palliative sedation. By using this step-by-step plan for palliative sedation, however, the decision-making process becomes multidisciplinary and diminishes the emotional burden for nurses. Moreover, it brings about clarity among care providers on when palliative sedation is and is not an issue.

An essential element in palliative care is striving for the best possible quality of life for each terminally ill patient and his or her family. To accomplish this goal, it is important to relieve the patient as much as possible of unpleasant physical, psychological, social, or spiritual problems.[1,2] In recent years, a positive evolution has been noticed regarding the treatment of such physical symptoms as pain.[3] Research shows that on the whole, palliative care succeeds in adequately treating a number of symptoms, mainly physical,[4,5,6] but at the same time it is evident that many symptoms, although treated, are not accounted for sufficiently. Sometimes these symptoms concern physical problems but increasingly they include spiritual and existential problems.[7] These inadequately manageable symptoms are also called "refractory symptoms" and can be distinguished from other symptoms that are difficult to treat because contrary to the advice of many clinical experts, they cannot be treated without compromising the patient's consciousness.[7,8] These refractory symptoms often can have a significant adverse effect on the functioning and well-being of a patient[8,9] and increase in intensity as the patient approaches death.[10] Since 1990, some have begun to consider palliative sedation as the final therapeutic possibility.[11]

Despite the fact that palliative sedation can be considered a gradually accepted form of therapy within palliative care, research has shown that palliative sedation often involves a heavy emotional burden for care providers and, more specifically, for nurses.[12] It is chiefly the nurse who, after the palliative sedation has been initiated, is assigned the largest share of the subsequent follow-up and care of the sedated patient and his or her family. Morita et al[12] surveyed 3,187 nurses with the objective of identifying the extent of the emotional burden when confronted with the care of a patient who is undergoing palliative sedation. This research group also identified which factors possibly influence the emotional burden experienced. The study shows that 12% of the nurses experience palliative sedation as an additional burden, 12% feel helpless when a case of palliative sedation occurs, 11% try to avoid situations in which palliative sedation occurs, and 4% consider palliative sedation to be pointless.[12]

Factors such as a patient's unclear wishes as to palliative sedation, difficult-to-diagnose refractory symptoms, insufficient knowledge of palliative sedation, insufficient skills to deal with sedated patients and their families, differences in opinion between doctors and nurses, and conflicts between patient and family, and ethical uncertainties contribute to causing the extra burdens that the nurses experience in these situations and give rise to a certain form of incomprehension or distrust of the method of treatment.

For these reasons, we wish to explain in this article the way in which palliative sedation as a therapy fits into the care perspective of palliative nursing care, the way in which decision-making and the practical procedure of palliative sedation may be carried out (based on a step-by-step plan), and, concretely, the role the nurse can play.

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