Palliative sedation: beliefs and decision-making among Spanish palliative care physicians

To describe physician attitudes to deep palliative sedation.

A nationwide e-survey of Spanish palliative care specialists was performed using vignettes which described patients close to death with intractable symptoms. Sedation levels were defined according to the Richmond Agitation-Sedation Scale. Multivariate analyses were performed to assess the explanatory factors involved in decision-making.

Responses of 292 palliative care specialists were analyzed (response rate 40%). Ninety-four percent, 87%, and 81% of the respondents supported the use of palliative sedation in cases of irreversible refractory symptoms as hyperactive delirium and dyspnea at rest secondary to lung cancer and GOLD stage IV COPD; 60% agreed with the use of palliative sedation in cases of existential suffering. Logistic regression analysis found as the explanatory factor in not performing palliative sedation the physicians' belief that sedation therapy constitutes undercover euthanasia (OR = 12, p < 0.01). Around 80% of physicians who decided on palliative sedation chose deep/complete sedation for every vignette; there were no common explanatory factors for decision-making for every vignette. The belief that sedation therapy equates to undercover euthanasia justifies not performing deep sedation in cases of irreversible refractory agitated delirium (OR = 7) and irreversible intractable dyspnea (OR = 6). Physician background in palliative care and sedation were associated with the selection of deep/complete sedation in cases of refractory delirium and cancer-associated dyspnea.

Spanish palliative physicians generally agree with the use of deep sedation as a proportionate treatment in dying patients with refractory symptoms. Decision-making is associated with physician beliefs regarding euthanasia and with the physician's background in palliative care and sedation.