- Patients' characteristics showed no significant difference in the stage of disease on admission (Table ). But patients who finally received sedation were more likely to have experienced pain, dyspnoea and anxiety as the predominant symptom on admission than those who did not undergo sedation (Table ).
Table 2 Patients characteristics on admission – demographic and clinical data of all patients in comparison to those who died in PCU Havelhoehe 1995–2002. Significant differences were found between groups on age and stages on admission except (more ...)
Predominant and concomitant symptoms on admission to PCU Havelhoehe.
- Sedation in the last 48 hrs was performed in 14,6 % (n = 80) of all patients who died in the PCU of GK Havelhoehe (n = 548) with significantly increasing frequency in the years 2000–2002 (χ2 = 8.57; p = 0.003) (Figure ).
Figure 1 Percentage of patients with sedation in the last 48 hrs in relation to the number of annual deaths (bars) in care of PCU Havelhoehe between 1995 and 2002. Significant increase of incidence for sedation in the period 2000–2002 (p = 0.015 in paired (more ...)
- No difference was found in the duration of stay in our unit until death between those patients who died with, and those who died without sedation. Mean age of patients, who finally had sedation was less with 54 years vs. 64 years in those without sedation (p = 0.001, Student's t-test).
- All patients had effective and sufficient pain control, but in those patients who were sedated in the last 48 hrs of life, burdensome dyspnoea, panic-stricken anxiety and agitated delirium had increased during the stay (Figure ).
Figure 2 Course of pain, dyspnoea, cognitive disorder (delirium) and psychological distress (anxiety) in patients with regard to application of sedation in the final phase (A= Subgroup without sedation, B= Subgroup with sedation). Significance level p < (more ...)
- The indications for performing sedation due to predominant psychological distress (anxiety, refractory insomnia, decompensation) and due to refractory symptoms (dyspnoea, gastrointestinal, pain) did not differ significantly during the two observational periods. Interestingly, there was a tendency that the main indications for sedation during the last three years shifted more and more to psychological distress.
- Mean survival time after administration of sedation was 63 ± 58 hrs during the whole observation period. In the years 2000–2002 patients with more psychological distress had a longer survival time than those with otherwise resistant control of more physical symptoms (Table ).
Indication for sedation, patients' request and observational reports on communication and oral fluid/nutrition intake comparing the periods 1995–1999 and 2000–2002 (*p < 0.05).
- In the years 2000–2002 we noticed an increase in the request for sedation in the final days of life from 19% to 34% by the patients themselves, documented in personal statements or advance directives. In those patients in which sedation was given also "on request", the mean survival time was found to be slightly shorter (52 ± 42 hrs) in the years 2000–2002, but not in the years before (Table ).
- In most cases, sedation was performed with slowly increasing doses of midazolam 0,5 mg – 8 mg/h iv, aimed at achieving effective symptom control. When this was obtained, doses were reduced and sedation was continued intermittently with the documentation of the level of consciousness, comfort, eating, drinking and communication skills. 48 patients had continuous sedation (mean duration 53 hrs), 32 intermittent (mean duration 77 hrs). In 53 patients (66%) oral supply of fluids and in 10 patients also oral nutrition intake during sedation was reported in the records. 27 patients (33.8%), had no oral fluid or nutrition supply after sedation was introduced either because of the deepness of the sedation or because of refusal of oral fluid and nutrition intake. Infusion of fluids was continued in all patients with regard on comfort according to clinical signs of thirst with restriction of volumes in cases of oedema, ascites and pulmonary congestion. Special attention was given to establish a good sleeping period at night and a more patient controlled sedative state with communicative skills and reports of comfort during the day.
- Abilities to communicate like asking for help or answering questions on pain, comfort, thirst etc. and preserved forms of cooperation under sedation were reported in 40 cases (50%).
- The following case of a 40 yrs old hospice worker, in whom oropharyngeal cancer was diagnosed during pregnancy, may illustrate the procedure of sedation in our PCU but also the difficulties associated with drawing the line in consideration of patients needs, personal intentions and adequacy of sedative procedures for refractory symptom control:
For several weeks she was treated for panic attacks, dyspnoea and dysphagia but relief of symptoms only lasted a few days. Her weakness increased rapidly. In her advance directives she had disclaimed tracheotomy and antibiotics but pleaded for good pain therapy and sedation "to die in sleep". In the final phase she suffered from extensive mucositis, exhausting breathlessness and agitated anxiety by upper airway obstruction due to local tumour progression, pulmonary and hepatic metastases and acute pneumonia. She said: "I think – now the time has come" and requested for sedation during the last hours of her life. The clinical situation was discussed with the nursing team according to our internal guidelines. Informed consent in presence of her husband was obtained before 5 mg iv midazolam were administered with good symptom relief. Sedation was continued with a dosage of 1–2 mg/h on which the patient insisted on comfort by the sedation and fear of recurring distress. Survival time was 16 hrs in a peaceful, quiet atmosphere without distress, a light sedative state with diminished communication skills, oral fluid intake and support by the presence of her husband.