Olav Magnus Søndenå Fredheim

Background: Palliative sedation is considered an essential measure when other methods cannot provide sufficient symptom control in end-of-life. Prior research suggests that health care professionals find boundaries between palliative sedation, routine symptom management and euthanasia ambiguous. Appropriate implementation of palliative sedation depends on palliative care clinicians being confident in conceptual understanding of palliative sedation. The aim of this study was to understand specialist palliative care professionals' conceptualization of distinctions between symptom management, palliative sedation, and euthanasia; how perceived boundary ambiguities act as barriers to timely initiation of palliative sedation; and potential strategies to overcome these barriers. Methods: This is an explorative qualitative phenomenological study, based on focus group interviews, utilizing reflexive thematic analysis. Four focus groups were interviewed at specialist palliative care departments across four Norwegian hospitals. Participants were 11 nurses and 12 physicians with at least one year of experience within specialist palliative care. Results: Through thematic analysis two core themes were developed; the distinction between symptom management and palliative sedation, and the distinction between palliative sedation and euthanasia. Important sub-themes were definitional uncertainties, complexity of gradual medication titration, timing of sedation, indications for sedation, communication, and concerns about hastening death. Conclusion: Even within specialist palliative care, different end-of-life treatment concepts are not experienced clear-cut. These conceptual ambiguities impede appropriate initiation of palliative sedation. Overcoming such barriers requires multi-level interventions: enhancing practitioners' definitional knowledge, fostering awareness of clinical intention during end-of-life treatment, promoting interprofessional dialogue, and developing more explicit clinical guidelines.

Background Subcutaneous (SC) administration is the preferred parenteral opioid route in palliative care, while intravenous infusion may allow faster titration. Comparative evidence remains limited. This study assessed whether intravenous or SC morphine, administered by continuous infusion with bolus doses, offered advantages in (1) time to stable infusion rate and (2) time to pain relief following a bolus dose. Methods In this double-blind, double-dummy randomised controlled trial, 60 hospitalised palliative care patients with cancer requiring opioid rotation to parenteral morphine were randomised to continuous SC or intravenous infusion with bolus doses over 48 hours. Results Mean time to final infusion rate was 20.4 hours (95% CI: 15.2 to 25.6) for SC and 16.3 hours (95% CI: 10.5 to 22.2) for intravenous (mean difference: 4.1 hours, 95% CI: –3.6 to 11.7; p=0.293). Median time to effect from bolus doses was 20 min (Q1, Q3: 15, 23) for SC and 15 min (10, 20) for intravenous (HR=1.08, 95% CI: 0.61 to 1.88; p=0.795), indicating no significant difference. NRS scores decreased from 3.9 to 2.1 (SC) and 3.3 to 2.3 (intravenous). Infusion rates increased from 2.4 to 3.3 mg/hour, bolus doses from 4.6 to 6.6 mg. Of 604 boluses, the proportion of effective doses was similar between groups. One intravenous patient developed catheter-related thrombosis and infection post-intervention. Conclusion No statistically significant or clinically meaningful differences in effectiveness or safety were observed between SC and intravenous morphine administration. Both routes allowed similar titration patterns, supporting the use of either route in palliative care without compromising analgesic efficacy or safety.

Background: Data from other countries have indicated that palliative care physicians are more opposed to assisted dying compared with other physicians. However, little is known about reasons for support/opposition among palliative care physicians. Objectives: To explore Norwegian palliative care physicians’ attitudes toward assisted dying, with focus on filling knowledge gaps regarding reasons for support/opposition. Methods: The study is a cross-sectional descriptive survey. All 285 members of the Norwegian Association for Palliative Medicine were invited by e-mail to participate. To allow comparison with previous data, most questions and response alternatives were similar to a 2024 study of Norwegian physicians. Results: Among the 117 respondents opposition toward assisted dying was observed with 85 (73%) strongly disagreeing and 14 (12%) somewhat disagreeing with legalization of physician-assisted suicide for patients with short life expectancy. There was a clear pattern of less support for assisted dying if indications were wider, with only one respondent partially agreeing that assisted dying should be legalized for patients without severe illness who are tired of life and want to die. The most common reason for opposition was assisted dying representing a breach with professional ethics (88 subjects). The most common reason for support was that legalization could provide a safety for patients and next of kin that suffering could be avoided (14 subjects). Discussion: A large majority of Norwegian palliative care physicians reject the legalization of assisted dying. Among the small minority who support assisted dying, most believe it should be limited to patients with a short life expectancy.

Background: Global trigger tool (GTT) was developed for identification of patient harm. In palliative patients deterioration can be expected, and there are no data on whether cases classified as “patient harm” actually represents a potential for improved patient safety. Objectives: The primary aim was to test the performance and suitability of GTT in palliative care patients. The secondary aim was to pilot triggers for substandard palliative care. Design and Measurements: GTT was applied in 113 consecutive patients at a palliative ward at a Norwegian university hospital. Cases of patient harm were further evaluated to decide if the case was (a) a natural part of the disease trajectory or (b) a foreseeable consequence of treatment decisions. Potential triggers for substandard palliative care were tested. Results: Two hundred twelve triggers (1.9 per hospitalization) and 26 cases of patient harm were identified. The positive predictive value (PPV) for identifying patient harm was 0.12. The most prevalent harm was pressure ulcers (8.8%). Of the 26 cases of patient harm, 6 cases were a natural part of the disease trajectory and 10 consequences of treatment decisions. In 21 (18%) patients triggers being piloted for substandard palliative care were present, identifying 9 cases of substandard palliative care. The highest PPV (0.67) was observed for “Cessation of antibiotics less than 5 days before death.” Conclusions: With the exception of pressure ulcers, GTT triggers were infrequent or had a very poor PPV for patient harm. Triggers related to overtreatment might be suitable for identifying substandard palliative care.

14.02.2023: Debatt - Til tross for at pasienter med Parkinsons sykdom ofte har høyt symptomtrykk i slutten av sykdomsforløpet, henvises de sjelden til palliativ spesialisthelsetjeneste.

Background: A “Do not resuscitate” (DNR) order implies that cardiopulmonary resuscitation will not be started. Absent or delayed DNR orders in advanced chronic disease may indicate suboptimal communication about disease stage, prognosis, and treatment goals. The study objective was to determine clinical practice and patient involvement regarding DNR and the prevalence of life‐prolonging treatment in the last week of life.Methods: A cross‐sectional observational study was made of a cohort of 315 deceased from a large general hospital in Norway. Data on DNR and other treatment limitations, life‐prolonging treatment in the last week of life, and cause of death were obtained from medical records.Results: A DNR order was documented for 287 (91%) patients. Almost half the DNR orders, 142 (49%), were made during the last 7 days of life. The main causes of death were cancer (31%), infectious diseases (31%), and cardiovascular diseases (19%). The most frequent life‐prolonging treatments during the last week of life were intravenous fluids in 221 patients (70%) and antibiotics in 198 (63%). During the last week of life, 103 (36%) patients received ICU treatment. Death by cancer (odds ratio 2.5, 95% confidence interval 1.24–5.65) and DNR decision made by a palliative care physician (odds ratio 3.4, 95% CI 1.21–3.88) were predictors of not receiving life‐prolonging treatment.Conclusion: The findings of a high prevalence of life‐prolonging treatment in the last week of life and DNR orders being made close to the time of death indicate that decisions about limiting life‐prolonging treatment are often postponed until the patient's death is imminent.

Background Deep palliative sedation (DPS) is applied as a response to refractory suffering at the end of life when symptoms cannot be relieved in an awake state. DPS entails a dilemma of whether to provide uninterrupted sedation—in which case DPS would turn into deep and continuous palliative sedation (DCPS) —to minimise the risk that any further intolerable suffering will occur or whether to pause sedation to avoid unnecessary sedation. DPS is problematic in that it leaves the patient ‘socially dead’ by eradicating their autonomy and conscious experiences. Aim To perform a normative ethical analysis of whether guidelines should recommend attempting to elevate consciousness during DPS. Design A structured analysis based on the four principles of healthcare ethics and consideration of stakeholders’ interests. Results When DPS is initiated it reflects that symptom relief is valued above the patient’s ability to exercise autonomy and experience social interaction. However, if a decrease in symptom burden occurs, waking could be performed without patients experiencing suffering. Such pausing of deep sedation would satisfy the principles of autonomy and beneficence. Certain patients require substantial dose increases to maintain sedation. Waking such patients risks causing distressing symptoms. This does not happen if deep sedation is kept uninterrupted. Thus, the principle of non-maleficence points towards not pausing sedation. The authors’ clinical ethics analysis demonstrates why other stakeholders’ interests do not appear to override arguments in favour of providing uninterrupted sedation. Conclusion Stopping or pausing DPS should always be considered, but should not be routinely attempted.

Purpose Pain management principles vary considerably between chronic noncancer, acute and cancer pain. Cancer patients responding to oncological treatment may live with low tumor burden for years. Opioid treatment should reflect that the ratio between benefits and risks in these patients is different from patients with a rapidly progressive disease. Our study investigated the prescription patterns of analgesics in patients who died 6 to 9 years after cancer diagnosis. Patients and methods A pharmaco-epidemiological study based on the Norwegian Prescription Database and Cancer Registry of Norway. The 1-year periodic prevalence of receiving different analgesics and of persistent opioid use were analyzed. Persistent opioid use was defined as >365 Defined Daily Doses or >9000 mg Oral Morphine Equivalents during 365 days with prescriptions in all quarters of the 365 days period. Data were reported for the first 7 years for patients who lived 8–9 years after cancer diagnosis (N = 1502), while for patients who lived 6–7 years (N = 3817) data was reported for the first 5 years after diagnosis. Results Compared to age- and gender adjusted general population, the 1-year periodic prevalence of opioid prescription was doubled the first year after diagnosis and remained raised with approximately 50%. The prevalence of persistent opioid use was threefold of the general population. Approximately 55% of patients with persistent opioid use 4 years after a cancer diagnosis were co-medicated with high doses of benzodiazepines and/or benzodiazepine-related hypnotics. Conclusion The findings of increased opioid use raise concerns regarding whether the benefits outweigh risks and side effects in this population.

Background: The anesthetic propofol is often mentioned as a drug that can be used in palliative sedation. The existing literature of how to use propofol in palliative sedation is scarce, with lack of information about how propofol could be initiated for palliative sedation, doses and treatment outcomes.Aim: To describe the patient population, previous and concomitant medication, and clinical outcome when propofol was used for palliative sedation.Methods: A retrospective study with quantitative and qualitative data. All patients who during a 4.5‐year period received propofol for palliative sedation at the Department of palliative medicine, Akershus University Hospital, Norway were included.Results: Fourteen patients were included. In six patients the main indication for palliative sedation was pain, in seven dyspnoea and in one delirium. In eight of these cases propofol was chosen because of the pharmacokinetic properties (rapid effect), and in the remaining cases propofol was chosen because midazolam in spite of dose titration failed to provide sufficient symptom relief. In all patients sedation and adequate symptom control was achieved during manual dose titration. During the maintenance phase three of 14 patients had spontaneous awakenings. At death, propofol doses ranged from 60 to 340 mg/hour.Conclusions: Severe suffering at the end of life can be successfully treated with propofol for palliative sedation. This can be performed in palliative medicine wards, but skilled observation and dose titration throughout the period of palliative sedation is necessary. Successful initial sedation does not guarantee uninterrupted sedation until death.Editorial Comment: In palliative care, some patients at the end of life can reach a stage where there have been maximal analgesic and or anxiolytic treatments though without achieving comfort in the awake state. This report describes and discusses use of propofol in these infrequent cases to relieve suffering as part of palliative care.

13.01.2020: Kommentar - Vi takker Ø.