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The complexity of nurses' attitudes and practice of sedation at the end of life: a systematic literature review |
Abarshi EA, Papavasiliou ES, Preston N, Brown J, Payne S, EURO IMPACT |
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CRD summary This review explored nurses' attitudes and practice relating to the sedation of patients at the end of their life. The authors concluded that most nurses administered sedation, until death, only where it was necessary to control refractory symptoms and suffering; some nurses experienced burdens when delivering sedation. Reporting limitations restrict the confidence in the reliability of this conclusion. Authors' objectives To explore nurses' attitudes and practice relating to the sedation of patients at the end of their life. Searching Eight electronic databases (including PubMed and EMBASE) were searched for peer-reviewed English-language articles published between 1990 and 2012. Search terms were reported. A manual search was carried out of the reference lists of included studies, and in selected journals, and for relevant dissertations and grey literature. Study selection Eligible for inclusion were studies of nurses' attitudes and practice in relation to palliative sedation of terminally ill patients aged 18 years or older. Palliative sedation was defined as "inducing a state of decreased or absent consciousness until death, in the last phase of life of a terminally ill patient, by monitored use of sedatives, as a last resort means of relieving unbearable symptoms or suffering". Case studies and conference abstracts were excluded. The included studies were conducted in seven different countries, with one study in the UK. Patients had a range of conditions (reported in the paper) and were cared for at home, in a nursing home, in a hospice or palliative care unit, or in hospital. Nursing experience ranged from six months to 29 years, and nurses had varying skills in end of life care. Various definitions of palliative sedation were used. The methods of data collection included questionnaires (quantitative), and focus groups and interviews (qualitative). Two reviewers independently selected the studies for inclusion on the basis of title and abstract. Disagreements were resolved by retrieving the full text, or by consultation with a third reviewer. Assessment of study quality Study quality was assessed, using established checklists for studies of mixed design. This assessment focused on the evidence of relevance to the research question, clarity of reporting, and methodological rigour. Quality was assessed on a scale from 0 (very poor) to 3 (good). It was then graded, using Gough's weight of evidence, as high, medium, or low. The number of reviewers who assessed quality was not reported. Data extraction The data were extracted and themes were identified and coded systematically. Relationships between findings across different care settings and countries were explored. It appears that four reviewers were involved in this process. A fifth reviewer (a specialist in palliative care research and practice) was consulted, if necessary. Methods of synthesis The findings were synthesised in a thematic narrative synthesis, with three headings (according to an earlier review; see Other Publications of Related Interest). Results of the review Ten studies (7,515 nurses) were included in the review; five were quantitative, four were qualitative, and one had mixed methods. All studies were generally at least medium quality, with eight studies being high quality for relevance of the evidence in answering the research question. Generally, nurses had a positive, but cautious attitude towards the practice of palliative sedation. Most regarded it as a last resort for the relief of suffering and refractory symptoms. Important factors leading to the patient receiving palliative sedation: These factors arose from varying degrees of distress, experienced by nurses, in relation to their patients' protracted illness and its refractory symptoms. Some nurses felt that end-of-life needs assessment was challenging. Poor team dynamics, insufficient knowledge and skills (and the effect this had on communication with patients and carers), and perceived inappropriate timing of sedation had a negative impact on nurses' attitudes and practice. Nurses' attitudes towards palliative sedation: There were mixed feelings about palliative sedation. In many studies, nurses thought it was a useful last resort to create comfort and quality of care for patients, and improve the well-being of those around them. Others perceived the practice to be "ethically difficult" and similar to euthanasia, preferring a stepwise approach that allowed all decision makers (including patients and caregivers) to reconsider sedation. Nurses' experience at the end of a patient's life: Concerns about the appropriateness and timing of palliative sedation were again raised by nurses in the phase after sedation. The support of peers, team members, and the providing organisation were important at this stage, as was the availability of practice guidelines. Authors' conclusions Most nurses administered sedation, until death, only where it was necessary to control refractory symptoms and suffering. Some nurses experienced burdens when delivering palliative sedation. CRD commentary The research question was clear and the inclusion criteria were broad. Relevant data sources were searched, and both published and unpublished articles were considered. Study selection was based on titles and abstracts, and some attempts were made in other review processes to maximise consistency, and avoid error and bias. Adequate study details were provided, and the quality assessment criteria were appropriate. The quality of included studies seems to have been satisfactory. The method of synthesis was outlined, and data interpretations were reported. The process of data extraction (including systematic coding and seeking relationships across studies), and attempts to triangulate between different methods of data collection, were not fully evidenced or explored. The authors paid attention to inconsistent data, and the findings were presented with counter arguments (where appropriate) within the results section. The studies were varied, so the transferability of the findings across populations and settings is unclear. The authors' conclusion reflects the evidence presented, but some reporting limitations restrict the confidence in it's reliability. Implications of the review for practice and research Practice: The authors stated a number of recommendations for clinical practice (reported fully in the paper). These related to the use of incremental sedation; application of a simple decision-making communication tool; improved education and relevant training on end-of-life issues for nurses, clinicians, patients and relatives; and the need for clear practice guidelines. Research: The authors stated that more research was needed generally for palliative sedation, and specifically for titration techniques. Exploration of nurses' attitudes was needed for related practices, such as hydration and feeding during palliative sedation. Cultural differences and their impact on practice, and an agreed definition for palliative sedation required further attention. Funding Funded by the European Union Seventh Framework Programme. Bibliographic details Abarshi EA, Papavasiliou ES, Preston N, Brown J, Payne S, EURO IMPACT. The complexity of nurses' attitudes and practice of sedation at the end of life: a systematic literature review. Journal of Pain and Symptom Management 2014; 47(5): 915-925.e11 Other publications of related interest Engstrom J, Bruno E, Holm B, Hellzen O. Palliative sedation at end of life — a systematic literature review. European Journal of Oncology Nursing 2007; 11: 26-35. Indexing Status Subject indexing assigned by NLM MeSH Attitude of Health Personnel; Humans; Hypnotics and Sedatives /therapeutic use; Nurses /psychology; Palliative Care /methods /psychology; Terminal Care /methods /psychology AccessionNumber 12013058694 Date bibliographic record published 08/11/2013 Date abstract record published 28/11/2013 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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