Ziegler Sarah, Merker Hannes, Schmid Margareta, Puhan Milo A
Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland.
BMC Palliat Care. 2017 May 8;16(1):30. doi: 10.1186/s12904-017-0205-0.
The practice of continuous deep sedation is a challenging clinical intervention with demanding clinical and ethical decision-making. Though current research indicates that healthcare professionals' involvement in such decisions is associated with emotional stress, little is known about sedation-related emotional burden. This study aims to systematically review the evidence on the impact of the inpatient practice of continuous deep sedation until death on healthcare professionals' emotional well-being.
A systematic review of literature published between January 1990 and October 2016 was performed following a predefined protocol. MEDLINE, EMBASE, PubMed, Cochrane Library, CINAHL, Scopus, and PsycINFO were searched using search terms within "end-of-life care", "sedation", and "emotional well-being". Dissertations and reference lists were screened by hand. Two independent reviewers conducted study selection, data extraction and quality assessment. We abstracted measures of psychological outcomes, which were related to the practice of continuous deep sedation until death, including emotional well-being, stress and exhaustion. We used the GRADE approach to rate the quality of evidence.
Three studies remained out of 528 publications identified. A total of 3'900 healthcare professionals (82% nurses, 18% physicians) from Japan (n = 3384) and the Netherlands (n = 16) were included. The prevalence of sedation-related burden in nurses varied from 11 to 26%, depending on outcome measure. Physicians showed medium levels of emotional exhaustion and low levels of depersonalization. Common clinical concerns contributing to professionals' burden were diagnosing refractory symptoms and sedation in the context of possibly life-shortening decisions. Non-clinical challenges included conflicting wishes between patients and families, disagreements within the care team, and insufficient professionals' skills and coping. Due to the limited results and heterogeneity in outcome measure, the GRADE ratings for the quality of evidence were low.
Current evidence does not suggest that practicing continuous deep sedation is generally associated with lower emotional well-being of healthcare professionals. Higher emotional burden seems more likely when professionals struggled with clinical and ethical justifications for continuous deep sedation. This appeared to be in part a function of clinical experience. Further research is needed to strengthen this evidence, as it is likely that additional studies will change the current evidence base.
持续深度镇静是一项具有挑战性的临床干预措施，需要严格的临床和伦理决策。尽管目前的研究表明，医疗保健专业人员参与此类决策会带来情绪压力，但对于与镇静相关的情绪负担却知之甚少。本研究旨在系统回顾关于住院患者持续深度镇静直至死亡对医疗保健专业人员情绪健康影响的证据。
按照预先确定的方案，对1990年1月至2016年10月期间发表的文献进行系统回顾。使用“临终关怀”、“镇静”和“情绪健康”相关的检索词，对MEDLINE、EMBASE、PubMed、Cochrane图书馆、CINAHL、Scopus和PsycINFO进行检索。通过手工筛选论文和参考文献列表。两名独立的评审员进行研究选择、数据提取和质量评估。我们提取了与持续深度镇静直至死亡的实践相关的心理结果测量指标，包括情绪健康、压力和疲惫。我们使用GRADE方法对证据质量进行评级。
在识别出的528篇出版物中，有三项研究入选。共有来自日本（n = 3384）和荷兰（n = 16）的3900名医疗保健专业人员（82%为护士，18%为医生）参与。根据结果测量指标，护士中与镇静相关负担的发生率在11%至26%之间。医生表现出中等程度的情绪疲惫和低程度的去个性化。导致专业人员负担的常见临床问题包括在可能缩短生命的决策背景下诊断难治性症状和进行镇静。非临床挑战包括患者与家属之间相互冲突的愿望、护理团队内部的分歧以及专业人员技能和应对能力不足。由于结果有限且结果测量指标存在异质性，证据质量的GRADE评级较低。
目前的证据并不表明实施持续深度镇静通常与医疗保健专业人员较低的情绪健康相关。当专业人员在持续深度镇静的临床和伦理依据方面存在困难时，情绪负担似乎更高。这似乎部分是临床经验的作用。需要进一步的研究来加强这一证据，因为很可能更多的研究会改变当前的证据基础。
