Conceptual barriers to palliative sedation: insights from focus group interviews with specialist palliative care...

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.

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.

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.

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.