CONTEXT: Few studies regarding palliative sedation (PS) have been carried out in home care (HC) setting. A comparison of PS rate and practices between hospice (HS) and HC is also lacking.
OBJECTIVES: Comparing HC and HS settings for PS rate, patient clinical characteristics before and during PS, decision-making process and clinical aspects of PS.
METHODS: 38 HC/HS services in Italy participated in a multicenter observational longitudinal study. Consecutive adult cancer patients followed till death during a four-month period and undergoing PS were eligible. Symptom control and level of consciousness, , were registered every 8h to death.
RESULTS: 4276 patients were screened, 2894 followed till death and 531 (18%) underwent PS. PS rate was 15% in HC, 21% in HS (p<0.001). Principal refractory symptoms were delirium (54%) and dyspnea (48%), respectively more common in HC (p<0.001) and HS (p=0.03). Informed consent was not obtained in 72% of patients but achieved by 96% of families. Midazolam was the most used drug, (94% HS vs 75% HC, p<0.001) mainly by continuous infusion (74% HC vs 89% HS, p<0.001). PS duration was <48h in 67% of patients. Hydration during PS was less frequent in HC (27% vs 49%, p<0.001). In the 8h before death, consciousness level was "unrousable to mild physical stimulation" in 81% and symptom control "complete" in 89% of cases.
CONCLUSION: Our results show feasibility of PS in HC and HS, and suggest setting differences in rates, indications and practice of PS, possibly related to patients selection or care organization.
Advance care planning (ACP) is increasingly implemented in oncology and beyond, but a definition of ACP and recommendations concerning its use are lacking. We used a formal Delphi consensus process to help develop a definition of ACP and provide recommendations for its application. Of the 109 experts (82 from Europe, 16 from North America, and 11 from Australia) who rated the ACP definitions and its 41 recommendations, agreement for each definition or recommendation was between 68-100%. ACP was defined as the ability to enable individuals to define goals and preferences for future medical treatment and care, to discuss these goals and preferences with family and health-care providers, and to record and review these preferences if appropriate. Recommendations included the adaptation of ACP based on the readiness of the individual; targeting ACP content as the individual's health condition worsens; and, using trained non-physician facilitators to support the ACP process. We present a list of outcome measures to enable the pooling and comparison of results of ACP studies. We believe that our recommendations can provide guidance for clinical practice, ACP policy, and research.