Palliative Care Nurses’ Ethical Dilemmas: Literature Review of Palliative Sedation When Patients Reach End-of-life Stage

Contents Page:

Acknowledgement………………………………………………………………………………..p 2

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1.0 Introduction…………………………………………………………………………………….p 3                                                                                                   

2.0 Background and Rationale………………………………………………………………p 3                                                    

3.0 Search Strategy………………………………………………………………………………p

4.0 Literature review: Emergent themes…………………………………………………p

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4.1 Nurses’ experiences towards decision making…………………………………p

4.2 The perception of hastening death…………………………………………………..p

5.0 Impact of Key Findings……………………………………………………………………p

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6.0 Conclusion……………………………………………………………………………………..p

References……………………………………………………………………………………………p

Bibliography…………………………………………………………………………………………p

Appendix………………………………………………………………………………………………p

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 Exploring palliative care nurses’ ethical dilemmas: an international literature review of palliative sedation when patients reach end-of-life stage.

1.  Introduction

The aim of this literature review is to explore national and international research studies pertinent to ethical dilemmas experienced by Palliative Care (PC) nurses when caring for patients requiring Palliative Sedation (PS) at the end-of-life stage. The review starts with a contextual background and a rationale followed by a search strategy outlining the key words used in the search process, as well as outlining the databases and the time period covered with its justification. The identification and selection of the emergent themes emanating from the literature are then provided, highlighting key findings and the studies methodological strengths and limitations. A discussion of the key findings is presented and considerations on the impact or changes to nurses’ practice within palliative care settings are identified. To conclude a summary and reflective account are provided, and suggestions are made for consideration of future research and practice development.

2. Background and Rationale

480 000 people die in England every year, with an estimated increase of 550 000 by 2035 (DoH, 2015). NHS England (2014) estimated that each year approximately 170 000 people receive specialist PC.  In 2008 the DoH published its ‘End of Life Care Strategy’ which set out to recognise the needs of terminally ill individuals to provide a ‘good death’. Individuals’ needs were identified as being: surrounded by family in familiar surroundings in a place of their choice, treated with dignity and respect, their wishes acted upon at the right time, and being without pain and other symptoms involving specialised services and practitioners (DoH, 2008, 2015). Patients’ who require interventions for refractory symptoms, need to be surrounded by a multidisciplinary team and all aspects of their suffering need to have been explored before PS can be considered. The term ‘refractory symptoms’ refers to symptoms which cannot be alleviated despite extensive efforts to find a therapy that is tolerated and which does not compromise patients’ awareness and responsiveness (Cherny, 2014). Moral, legal and ethical issues need to be contemplated when patients reach end of life stage (Nunn, 2010).

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Over the past two decades PS has remained a controversial and much debated topic in PC. The World Health Organisation (2017) defines PC as being a practice which aims to improve the quality of life of terminally ill patients and their families, putting into place a system of support to alleviate their psychosocial, physical or spiritual suffering. The European Association for Palliative Care (EAPC, 2009) recognises that in order to lessen the burden of refractory symptoms and distress, PS has been an approach which is essential and significant in the case of selected patients who are terminally ill. In this context PS is described as an ethically acceptable therapeutic intervention by patients, families and health-care workers to decrease the patients’ consciousness in order to relieve them from intractable suffering (EAPC, 2009). Nurses are at the forefront of patient care and play and a key role in palliative and hospice care (Dobrina, 2014).  Whilst caring for patients at the end of life, nurses are faced with decision-making dilemmas and emotional burden, and for some this including the belief that PS is hastening patients’ death (Morita, 2004).

3.0 Search strategy:

This literature review was intended to look at the experiences of PC nurses working in hospice settings, however due to the paucity of research available, the search was extended to nurses working in other PC settings.  An electronic search of the following key words was conducted : ‘Palliative sedation’, ‘nurses’, ‘end of life’, ‘hospice’, ‘ethical dilemmas’ and ‘palliative care’. These terms were used singularly and / or in combination with the purpose of accessing relevant literature. The databases accessed were ‘CINAHL’ which yielded 11 relevant articles, including two systematic reviews.  ‘Medline’ yelded 4 relevant articles including two qualitative studies, ‘Pubmed’ yielded 7 relevant articles including one audit review and five qualitative studies, ‘Internurse’ produced 1 triangulated study and one systematic review and the Cochrane Library which produced one systematic review. Only the availability of ‘Full text’ was requested from these databases. Professional website such as NICE, Department of Health (DoH) and the World health Organisation (WHO) were also used to strengthen the outcome of the search strategy. Manual search of references used in texts was also completed. In order to focus on contemporary evidence based information, the search time parameter used was between 2007 and 2017. The search extended to international literature due to the paucity of research carried out in the United Kingdom (UK) and only included research printed in the English language. This strategy allowed for a comparison of the studies carried out in the UK and abroad, and the plausibility of the transferability of the findings. The results yielded from the databases can be seen in Appendix 1.

An inclusion and exclusion search criteria of the literature was identified and included in Table 1.

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Table 1. Search Inclusion and Exclusion Criteria