The practice of continuous palliative sedation in elderly patients: a nationwide explorative study among Dutch nursing home physicians.

OBJECTIVES To study the practice of continuous palliative sedation (CPS) by Dutch nursing home physicians in 2007. DESIGN A structured retrospective questionnaire. SETTING Nationwide nursing home physician study in the Netherlands. PARTICIPANTS One thousand two hundred fifty-four nursing home physicians received a questionnaire concerning their last case of CPS in 2007; 54% (n=675) responded. MEASUREMENTS Characteristics of CPS and requests for euthanasia were measured. RESULTS Three hundred sixteen patients were described. The majority had cancer or dementia. The most-reported refractory symptoms were pain (52%), anxiety (44%), exhaustion (44%), dyspnea (40%), delirium (24%), loss of dignity (18%), and existential distress (16%). In 98% of cases, CPS was aimed at symptom relief. Of patients with cancer, 17% had previously requested euthanasia. The mean starting dose of midazolam was 31 mg every 24 hours (range 0-240 mg/24 h), and the mean end dose was 48 mg every 24 hours (range 0-480 mg/24 h). CONCLUSION In addition to physical symptoms, anxiety, exhaustion, loss of dignity, and existential distress are often mentioned as refractory symptoms in the decision to start CPS by nursing home physicians. Furthermore, close to one in five patients with cancer had made a previous request for euthanasia. The dosage range of midazolam in this study fits the recommendations of the Dutch national guideline on palliative sedation, although international studies show smaller dosage ranges. Finally, prospective research about the acceptability and assessment of nonphysical symptoms as indications for CPS is recommended.