title: Considerations of physicians about the depth of palliative sedation at the end of life.
abstract: BACKGROUND
  Although guidelines advise titration of palliative sedation at the end of life, in practice the depth of sedation can range from mild to deep. We investigated physicians' considerations about the depth of continuous sedation.
  
  
  METHODS
  We performed a qualitative study in which 54 physicians underwent semistructured interviewing about the last patient for whom they had been responsible for providing continuous palliative sedation. We also asked about their practices and general attitudes toward sedation.
  
  
  RESULTS
  We found two approaches toward the depth of continuous sedation: starting with mild sedation and only increasing the depth if necessary, and deep sedation right from the start. Physicians described similar determinants for both approaches, including titration of sedatives to the relief of refractory symptoms, patient preferences, wishes of relatives, expert advice and esthetic consequences of the sedation. However, physicians who preferred starting with mild sedation emphasized being guided by the patient's condition and response, and physicians who preferred starting with deep sedation emphasized ensuring that relief of suffering would be maintained. Physicians who preferred each approach also expressed different perspectives about whether patient communication was important and whether waking up after sedation is started was problematic.
  
  
  CONCLUSIONS
  Physicians who choose either mild or deep sedation appear to be guided by the same objective of delivering sedation in proportion to the relief of refractory symptoms, as well as other needs of patients and their families. This suggests that proportionality should be seen as a multidimensional notion that can result in different approaches toward the depth of sedation.
authors.affiliation: Department of Public Health, Erasmus MC, Rotterdam, Netherlands. s.swart@erasmusmc.nl
authors.forename: Siebe J
authors.initials: SJ
authors.lastname: Swart
authors.forename: Agnes
authors.initials: A
authors.lastname: van der Heide
authors.forename: Lia
authors.initials: L
authors.lastname: van Zuylen
authors.forename: Roberto S G M
authors.initials: RS
authors.lastname: Perez
authors.forename: Wouter W A
authors.initials: WW
authors.lastname: Zuurmond
authors.forename: Paul J
authors.initials: PJ
authors.lastname: van der Maas
authors.forename: Johannes J M
authors.initials: JJ
authors.lastname: van Delden
authors.forename: Judith A C
authors.initials: JA
authors.lastname: Rietjens
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D003657:Decision Making; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D010166:Palliative Care / Q000379:methods*; D010820:Physicians; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000379:methods*
chemical_list: D006993:Hypnotics and Sedatives