Physicians’ Experiences and Perceptions of Environmental Factors Affecting Their Practices of Continuous Deep Sedation until Death: A Secondary Qualitative Analysis of an Interview Study
Abstract
:1. Introduction
2. Methods
2.1. Study Design
2.2. Study Context
2.3. Primary Study: Research Paradigm
2.4. Primary Study: Participants and Recruitment
2.5. Primary Study: Data Collection
2.6. Primary Study: Ethical Considerations
2.7. Secondary Study: Secondary Qualitative Analysis
3. Results
3.1. Participant Characteristics
3.2. Environmental Factors
3.2.1. Structure: Meso
The Lack of Professional and/or Technical Support in Monitoring Sedated Patients
“As I am the physician, I always initiate the first step. And that works well. But it is up to the nurse to actually put their chair next to bed, so to speak, and adjust the doses so that the patient doesn’t wake up. You have to act very quickly. So that implies that you need to be with the patient all the time. In a nursing home, CDS cannot go well. Mostly there is only one nurse practitioner responsible for an entire corridor with patients. Here, too, where there is a lack of nurse practitioners, I don’t dare to initiate CDS.”(Geriatrician)
The Use of Guidelines in Team Contexts
The Time Constraints for Treating Individual Patients and Pressure of Work
“On the one hand, there is this extensive guideline. Firstly, it take some time to read it. Secondly, it devotes many pages to the conditions of CDS. This is explained in great detail. Then there is a short summary, which mainly focuses on the dosages in which starting schedule is added. The drugs have to be monitored every two hours. In practice, this is not always that easy. Monitoring CDS the way we are supposed to according to the guidelines. As a general practitioner, you lose a lot of time. You have to check the patient regularly during the CDS. That is not always possible in practical terms. Especially since they want us to treat more and more patients. So it is a matter of increasing the doses sometimes.”(General practitioner)
3.2.2. Structure: Macro
The Structural Knowledge Gap in Medical Education
“There is insufficient training for CDS and also insufficient knowledge. I have never had training on palliative sedation either. I never had anything about palliation. So a lot of doctors do not know what CDS means. Whatever their background is, they just think: “We will give them a bit of Midazolam and they will sleep. If it needs to go a bit faster? Then we should give them a bit more. After that, we add a little morphine. They think that CDS is pretty simple.”(Geriatrician)
The Legal Context for Assisted Dying
“There are also a number of questions in that registration document about assisted dying that are not always easy to answer, for example, that you have to specify what exactly is unbearable suffering. That is one thing. And then there is the practical side of the registration. You have to take it to the post office. You have to send it by registered mail.. You have to register all of this in your patient file. In itself, that is quite a lot of work for something in which we have already invested a lot of time and energy. And I know that many general practitioners often think: “You know, I have really invested a lot of time, energy and effort for this, for which I have been paid little or nothing. But I also have to spend another half hour filling in the paperwork for the registration and another half hour going to the post office to get everything done, waiting in line and so on.” I also notice that colleagues ask questions about this and that this is a barrier preventing them from doing it. And then sometimes CDS is chosen.”(GP)
The Lack of a Clear Legal Context for CDS
“I think it is desirable for there to be legislation on CDS and for it to be written a bit like a guideline of how to carry things out, that you have to start at a certain dose depending on the weight of the patient, and that you then have to re-evaluate and document whether the patient is comfortable or not, and that you may then adjust the drugs proportionally. I think everyone has their own method now, because there is very little that is clear and black-and-white due to the lack of legislation.”(Intensive care physician)
3.2.3. Culture: Meso
The Moral Reservations of Care Teams and/or Institutions towards CDS
“The annoying thing is that you always get caught up in all those ethics. Some physicians say: “You cannot do that. Being so deeply sedated? And is that ethically acceptable?” So yes, in that case I try to find the middle ground based on what I know from all the fields. And searching, and gaining experience. For example, I consult the professionals from intensive care, to achieve something that is acceptable for me, but also for them. How should I put it? Intellectually acceptable. But yes, in the end, the patient is not deeply sedated.”(Palliative care physician)
The Presence of a Palliative Care Culture within Care Teams and Institutions
“The biggest difference I see is in the nursing home where I am involved. I think we have a good palliative culture there, and we have also had a palliative care coordinator for the last year who was brought in solely for palliative care. We certainly give all the information about palliative care and CDS. So if you ask, “does everybody know what CDS entails?”, then it is certainly the intention for all our nurses to know what it means. When CDS is initiated, the coordinator will take the lead and support me and the nurses who sometimes take over the monitoring, but he will also support the resident’s family. That makes you feel, of course, as a GP, that you’re working in a medically authorized way and that makes things much easier.”(GP)
The Culture of Fear of Making Clinical Errors Regarding CDS among a Group of Physicians
The Professional Stigma of Performing Assisted Dying among Some of the Physician Population
“And then this ‘compromise’. Yes, I think that this is often done. I have already experienced situations in which I discuss a case with medical specialists about a patient with cancer who had requested assisted dying and they say: “No, we really cannot do that. And if the suffering gets too severe, then we can always do CDS.” So then this compromise is chosen. There should be a chance to be able to talk about life-shortening actions without coming before this ‘moral court’.”(General practitioner)
3.2.4. Culture: Macro
The Different Understandings of CDS in the Medical and Policy Fields
The Societal Taboo around Suffering at the End of Life and Natural Death
“That sometimes CDS is initiated too early is also due to pressure from the families. “And look at him lying here now. That is not good, let him sleep now.” And then, as a physician, you hit a bit of a wall and sometimes the dose is increased abnormally or other things are done with the intention of speeding things up. But then that is not always what was initially intended. But it is very often under pressure from our society that these things happen. We are not always used to seeing people die. But maybe that is a reality that we have to learn to deal with as physicians? And, yes, dying, they want you to keep people alive for as long as possible. But you should not talk about it too much. You should not do too much advanced care planning. But when they lie there. You cannot do that. That is not possible. Yes, it has to be ‘done’ yesterday rather than today. And that is the current society in which we are living nowadays.”(Intensive care physician)
4. Discussion
4.1. Summary of Main Findings
4.2. Strenghts and Limitations
4.3. Interpretation of the Findings
4.4. Recommendations and Implications
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Medical Specialty | N (%) |
---|---|
Oncology | 13 (28) |
General practice | 13 (28) |
Intensive care medicine | 12 (26) |
Geriatrics | 8 (17) |
Anesthetics | 1 (2) |
Additional medical training in palliative medicine * | 25 (53) |
Professional care setting | |
Hospital | 29 (62) |
Home | 18 (38) |
Age | |
<35 years | 7 (15) |
35–44 years | 8 (17) |
45–54 years | 15 (32) |
55–64 years | 12 (26) |
>64 years | 5 (11) |
Sex | |
Male | 26 (55) |
Female | 21 (45) |
Number of patients treated who had died in the 12 months prior to the interview | |
none | 0 (0) |
1–5 patients | 2 (4) |
6–10 patients | 7 (15) |
>10 patients | 38 (81) |
Number of continuous deep sedations performed in the 12 months prior to the interview | |
none | 0 (0) |
1–5 patients | 14 (30) |
6–10 patients | 5 (11) |
>10 patients | 28 (59) |
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Vissers, S.; Dierickx, S.; Robijn, L.; Cohen, J.; Deliens, L.; Mortier, F.; Chambaere, K. Physicians’ Experiences and Perceptions of Environmental Factors Affecting Their Practices of Continuous Deep Sedation until Death: A Secondary Qualitative Analysis of an Interview Study. Int. J. Environ. Res. Public Health 2022, 19, 5472. https://doi.org/10.3390/ijerph19095472
Vissers S, Dierickx S, Robijn L, Cohen J, Deliens L, Mortier F, Chambaere K. Physicians’ Experiences and Perceptions of Environmental Factors Affecting Their Practices of Continuous Deep Sedation until Death: A Secondary Qualitative Analysis of an Interview Study. International Journal of Environmental Research and Public Health. 2022; 19(9):5472. https://doi.org/10.3390/ijerph19095472
Chicago/Turabian StyleVissers, Stijn, Sigrid Dierickx, Lenzo Robijn, Joachim Cohen, Luc Deliens, Freddy Mortier, and Kenneth Chambaere. 2022. "Physicians’ Experiences and Perceptions of Environmental Factors Affecting Their Practices of Continuous Deep Sedation until Death: A Secondary Qualitative Analysis of an Interview Study" International Journal of Environmental Research and Public Health 19, no. 9: 5472. https://doi.org/10.3390/ijerph19095472