title: Prospective observational Italian study on palliative sedation in two hospice settings: differences in casemixes and clinical care.
abstract: OBJECTIVE
  Palliative sedation (PS) has been defined as the use of sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness. It is sometimes necessary in end-of-life care when patients present refractory symptoms. We investigated PS for refractory symptoms in different hospice casemixes in order to (1) assess clinical decision-making, (2) monitor the practice of PS, and (3) examine the impact of PS on survival.
  
  
  METHODS
  This observational longitudinal cohort study was conducted over a period of 9 months on 327 patients consecutively admitted to two 11-bed Italian hospices (A and B) with different casemixes in terms of median patient age (hospice A, 66 years vs. hospice B, 73 years; P = 0.005), mean duration of hospice stay (hospice A, 13.5 days vs. hospice B, 18.3 days; P = 0.005), and death rate (hospice A, 57.2% vs. hospice B, 89.9%; P < 0.0001). PS was monitored using the Richmond Agitation-Sedation Scale (RASS). Sedated patients constituted 22% of the total admissions and 31.9% of deceased patients, which did not prove to be significantly different in the two hospices after adjustment for casemix.
  
  
  RESULTS
  Patient involvement in clinical decision-making about sedation was significantly higher in hospice B (59.3% vs. 24.4%; P = 0.007). Family involvement was 100% in both hospices. The maximum level of sedation (RASS, -5) was necessary in only 58.3% of sedated patients. Average duration of sedation was similar in the two hospices (32.2 h [range, 2.5-253.0]). Overall survival in sedated and nonsedated patients was superimposable, with a trend in favor of sedated patients.
  
  
  CONCLUSIONS
  PS represents a highly reproducible clinical intervention with its own indications, assessment methodologies, procedures, and results. It does not have a detrimental effect on survival.
authors.affiliation: Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Maltoni
authors.forename: Guido
authors.initials: G
authors.lastname: Miccinesi
authors.forename: Piero
authors.initials: P
authors.lastname: Morino
authors.forename: Emanuela
authors.initials: E
authors.lastname: Scarpi
authors.forename: Francesco
authors.initials: F
authors.lastname: Bulli
authors.forename: Francesca
authors.initials: F
authors.lastname: Martini
authors.forename: Filippo
authors.initials: F
authors.lastname: Canzani
authors.forename: Monia
authors.initials: M
authors.lastname: Dall'Agata
authors.forename: Eugenio
authors.initials: E
authors.lastname: Paci
authors.forename: Dino
authors.initials: D
authors.lastname: Amadori
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003657:Decision Making; D003953:Diagnosis-Related Groups; D005260:Female; D017051:Hospice Care / Q000379:methods*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007558:Italy; D007902:Length of Stay; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000473:pathology; D010166:Palliative Care / Q000379:methods*; D010358:Patient Participation; D011446:Prospective Studies; D013727:Terminal Care / Q000379:methods*; D055815:Young Adult
chemical_list: D006993:Hypnotics and Sedatives