Palliative sedation does not shorten survival in the last days of life in patients with advanced cancer: A propensity score-weighted analysis of a prospective cohort study

Only 71 days to #EAPC2020 … The 11th World Research Congress of the European Association for Palliative Care which, for the first time ever, will take place online with interactive online sessions 7 to 9 October 2020 and on-demand content available from 21 September. 

Ahead of the congress, we’re delighted to give some highlights of what’s in store at #EAPC2020. Dr Naosuke Yokomichi, Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Japan, gives a glimpse of his plenary lecture.


Dr Naosuke Yokomichi.

“Is it to finish life?” A patient and his family may ask when we suggest to them palliative sedation. We would say, “No, to relieve your suffering. Generally, palliative sedation does not shorten life.”

But is it true? Are we really sure palliative sedation does not shorten life? How evident is it?

Although many studies have addressed whether palliative sedation shortens patient survival, the evidence is still limited because outcome measures of these studies were not appropriate. We aimed to overcome the methodological issues and to answer this important question in this multicentre prospective cohort study in Japan.

Imminently dying patients often experience a variety of distressing symptoms that include delirium, dyspnea, and pain. When symptoms become unbearable and refractory despite comprehensive and interdisciplinary palliative care, palliative sedation is a potential solution to provide relief of suffering. Generally, palliative sedation is defined as the use of sedative medications in dying patients to relieve intolerable suffering from refractory symptoms by a reduction of patient consciousness.

Continuous deep sedation (CDS) is a type of palliative sedation therapy in which sedative medications are administered with the intention of keeping a patient continuously comatose. It is ethically more controversial than other types of palliative sedation, because CDS is potentially life shortening as it contains a depressant effect on the brain stem which can cause perpetuating negative neurological, cardiovascular, respiratory and metabolic effects.For evidence-based discussion on the daily practice in palliative care, the clarification of whether CDS shortens patient survival is of great value.

While a randomised controlled trial seems to be difficult for this population, and generalisability of findings of clinical trials may not be fully applied to the real-world population; an observational study provides comprehensive insight into this topic. Until now, many observational studies have addressed the potential effect of palliative sedation on patient survival, none of which reported that palliative sedation or CDS shortened patients’ lives. A recent prospective cohort study revealed that CDS did not shorten patient survival from the time of enrolment into a palliative care programme until death after controlling for potential confounders using the propensity score-weighting method.Those studies, however, suffered major limitations and biases. The most critical issue was that the outcome measure was “essentially meaningless”.Survival from the time of enrolment of palliative care programme was too long to compare the effect of CDS on survival, because most CDS was performed in the last days of a patient’s life. In addition, previous studies included selection bias via an ambiguous definition of CDS or unfavourable handling of the missing values, or insufficient adjustment of confounders.

The primary aim of this study was to examine whether CDS shortens patient survival in the last days of life using 1,633 patient data from a multicentre prospective cohort study (EASED study), with precise statistical analysis to overcome the unresolved tasks from the previous studies.

We compared survival after a patient’s Palliative Performance Scale declined below 20 (PPS20) between CDS group and non-CDS group. Briefly, we found that the survival from PPS20 of patients with CDS was not significantly shorter than that in patients without CDS.

Now, we can explain to our patients and families with more confidence than before that palliative sedation is not associated with a measurable shortening of life in patients with advanced cancer. Palliative sedation is a viable palliative care option for alleviating refractory suffering in the last days. Effects of palliative sedation in patients with a better general condition should be studied in the future. I look forward to sharing more information with you at the EAPC World Research Congress Online.


Join Dr Naosuke Yokomichi at his plenary lecture, ‘Palliative sedation does not shorten survival in the last days of life in patients with advanced cancer: A propensity score-weighted analysis of a prospective cohort study’. His session will be available for registered delegates to view on demand from 21 September. Read the abstract of his lecture, and all other congress presentations and posters, in the Book of Abstracts for the 11th EAPC World Research Congress, ‘Palliative Medicine’, 2020 – available online from 21 September until January 2021. Keep up to date with the congress programme at https://eapcresearchcongress2020.eu/

References

  1. Twycross R. Reflections on palliative sedation. Palliat Care2019; 12: 1178224218823511.
  2. Maeda I, Morita T, Yamaguchi T, et al. Effect of continuous deep sedation on survival in patients with advanced cancer (J-Proval): a propensity score-weighted analysis of a prospective cohort study. The Lancet Oncology 2016; 17 (1): 115-22.

Links


JOIN PALLIATIVE CARE SPECIALISTS FROM ACROSS THE WORLD AT #EAPC2020 –11thEAPC WORLD RESEARCH CONGRESS ONLINE 2020 – interactive online sessions 7 to 9 October 2020 and on-demand content available from 21 September

A blend of Pre-recorded On-demand Sessions, Live Presentations, Live Panels hosted by international experts, Children’s Seminar, Poster Sessions, and EAPC Group Meetings will bring you all the latest research from the world’s top researchers in palliative and end-of-life care. CME accreditation will be available. Masses of content will be available on demand from 21 September until January 2021.  Learn and interact with leading researchers and chat with other registered delegates from the global palliative care community – all in the safety of your own home or office.

This entry was posted in 11th EAPC World Research Congress Online, EAPC World Research Congresses, Palliative sedation and tagged , . Bookmark the permalink.

1 Response to Palliative sedation does not shorten survival in the last days of life in patients with advanced cancer: A propensity score-weighted analysis of a prospective cohort study

  1. Richard Scheffer says:

    Dr Yokomichi’s research begs more questions than it answers. What is the evidence that patients, who need end-of-life sedation to relieve intractable suffering, are concerned about whether their life will be shortened or not? Are we caring for a patient’s needs or those of the clinician in seeking to show that our actions do not shorten a life of a dying person who is suffering unbearably? Are we as clinicians asking the right questions in our research? Where are the studies on what dying patients want? What do we know about conversations about sedation between dying people and clinicians? Would these people prefer other options? The practice of modern palliative care came about because Dame Cicely Saunders was appalled by the lack of honesty and paternalism of clinicians when dealing with dying that often resulted in increased distress. She sought to put the dying person and their needs at the centre of care. We run the risk of losing sight of that goal.

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