Characteristics Associated with Survival in Patients Receiving Continuous Deep Sedation in a Hospice Care Unit

Ahn, Hee Kyung,Ahn, Hong Yup,Park, So Jung,Hwang, In Cheol Korean Society for Hospice and Palliative Care 2021 한국호스피스.완화의료학회지 Vol.24 No.4

Continuous deep sedation (CDS) is an extreme form of palliative sedation to relieve refractory symptoms at the end of life. In this study, we shared our experiences with CDS and examined the clinical characteristics associated with survival in patients with terminal cancer who received CDS. We conducted a chart audit of 106 consecutive patients with terminal cancer who received CDS at a single hospice care unit between January 2014 and December 2016. Survival was defined as the first day of admission to the date of death. The associations between clinical characteristics and survival were presented as hazard ratios and 95% confidence intervals using a Cox proportional hazard model. The mean age of participants was 65.2 years, and 33.0% (n=35) were women. Diazepam was the most commonly administered drug, and haloperidol or lorazepam were also used if needed. One sedative was enough for a majority of the patients. Stepwise multivariate analysis identified poor functioning, a high Palliative Prognostic Index score, hyperbilirubinemia, high serum ferritin levels, and a low number of sedatives as independent poor prognostic factors. Our experiences and findings are expected to be helpful for shared decision-making and further research on palliative sedation.

호스피스 완화 병동에서 불응성 증상 조절을 위한 할로페리돌과로라제팜의 사용

남궁욱,김정민,어현선,정은진,김정아,이수형,박기현 대한가정의학회 2019 Korean Journal of Family Practice Vol.9 No.1

Background: Terminally ill cancer patients suffer from refractory symptoms, and the last option of treatment is to consider sedatives. However, due to concerns that sedation may shorten survival time, some people prefer not to take sedatives. The purpose of this study was to investigate the effects of sedative administration on survival time among terminally ill cancer patients. Methods: Two hundreds and thirty-seven patients who were hospitalized to the hospice care unit of public hospitals in Seoul from January, 2015 to March, 2016 were analyzed retrospectively. The univariate and multivariate Cox’s proportional hazard regression model was used to determine independent factors related to survival time. Results: The usage of sedation was necessary because the incidence of insomnia was 61.4% in the lorazepam only group, and the incidence of delirium was highest in the haloperidol group and the haloperidol with lorazepam group. Interestingly, multivariate analysis showed that male (HR, 1.766; P <0.001), decreased consciousness (HR, 1.803; P=0.003), anorexia (HR, 1.506; P=0.012), resting dyspnea (HR, 1.757; P<0.001), elevated serum bilirubin (HR, 1.657; P=0.001), and the haloperidol with lorazepam group (HR, 0.535, P<0.001) were each significantly associated with survival time. Furthermore, patients in the haloperidol with lorazepam group survived longer than patients with no such medications. Conclusion: There is no evidence that treatment with sedative medication shortens the survival time of patients with terminally ill cancer with refractory symptoms. 연구배경: 말기 암 환자들은 증상 조절이 되지 않는 신체적, 심리적불응성증상으로고통을받게되는데이때마지막치료로진정제투약을 고려하게 된다. 그러나 진정제 투약이 남은 생존기간을 단축시킨다는 우려 때문에 일각에서는 진정제 사용에 부정적이거나 소극적이기도 하다. 본 연구에서는 진정제 투약이 생존기간에 미치는 영향에 대해 알아보고자 하였다. 방법: 2015년 1월 1일부터 2016년 3월 31일까지 서울시 거점 공공병원 호스피스 완화병동에 입원 또는 전과되어 사망한 237명의 말기암 환자를 대상으로 후향적 의무기록 조사를 시행하였다. 진정제 투약이 필요하였던 불응성 증상을 분석하였으며, Cox’s proportionalhazard regression model을 이용한 단변량, 다변량 분석을 통하여 생존기간과 관련된 독립인자를 구하고 생존에 미치는 영향을 평가하였다. 결과: 진정제 사용이 필요한 사유를 살펴보면, lorazepam 사용군은불면이 61.4%, haloperidol 사용군과 haloperidol 및 lorazepam 모두 사용한 군에서는 섬망이 각각 82.4%, 76.2%로 가장 많았다. 생존기간에영향을 주는 요인에 대한 다변량 분석을 시행한 결과 남성(hazardratio [HR], 1.766; P<0.001), 의식 저하(HR, 1.803; P=0.003), 식욕 부진(HR, 1.506; P=0.012), 안정시 호흡곤란(HR, 1.757; P<0.001), 혈청 총 빌리루빈 상승(HR, 1.657; P=0.001), haloperidol 및 lorazepam 모두 사용(HR, 0.535; P<0.001) 모두 생존 기간에 대한 의미가 있는 독립적인 예후인자로 확인되었다. 결론: 불응성 증상이 동반된 말기 암 환자에게 진정제 투약이 생존기간을 단축시킨다는 근거는 없다고 할 수 있다. 진정제 투약이 필요한 상황이라고 판단된다면 환자의 증상 완화를 위해 지체 없이 시행하여 존엄한 삶의 마무리가 될 수 있도록 해야 한다.

단일 3차 의료 기관에서 완화적 진정 요법의 시행 빈도와 특성

송하나,임수진,이안나,이언석,강명희,이경원,강정훈 중앙대학교 의과대학 의과학연구소 2013 中央醫大誌 Vol.38 No.4

Background/Aims: Palliative sedation (PS) such as deep sedation is a practice using sedative agents to relieve refractory suffering of dying patients and widely used in clinical practice in western country. However, there is no report in Korea about the frequency and clinical characteristics of palliative sedation. Methods: The data were retrospectively collected by medical charts of patients who died at Gyeongnam regional cancer center from January 2009 to December 2012. Of eligible 2062 cohort patients, 41 (2.0%) patients received PS before death. We collected information about demographic characteristics, indication, sedative drugs. The dose of used opioids by converting morphine equivalent daily dose (MEDD) in each group was also compared under hypothesis that high dose opioids may induce delirium, which is the most common cause of PS. Results: We categorized 2,062 patients into two groups, patients with PS (n=41) and patients without PS (n=2,021). There were no differences in age, sex, primary site between two groups. Pain (n=19, 46.3%) is the most frequent indication of PS followed by delirium (n=11, 26.8%) and dyspnea (n=10, 24.4%), seizure (n=1, 2.4%) All the patients used midazolam as sedative drug with the median total dose of 108 mg/day. The median survival after PS was 3 days (confidence interval 95%, 1~35 days). MEDD was significantly higher in the patients with PS than patients without PS (2,112 mg vs 178 mg, p <0.001) Conclusions: Although PS has established role in dying patients, PS is not commonly used in clinical practice in Korea. Further research and education are warranted on this field in Korea.

Current Status and Future Directions of Research on Palliative Sedation

In Cheol Hwang 한국호스피스완화의료학회 2022 한국호스피스.완화의료학회지 Vol.25 No.4

Patients with terminal cancer experience very severe symptoms during the end of life, and palliative sedation (PS) may be considered if those symptoms are refractory to any other treatment. This brief report presents ethical considerations, practices, and recent concerns on PS. PS is quite different from euthanasia. There is a lack of consensus and standards on protocols, but its notable effects have been reported in hospice care settings. Most studies to date have reported no difference in survival between patients receiving PS and those not, and PS must be conducted proportionally with the lightest level of sedation. The most common indication for PS is delirium, and midazolam is the main sedative used. It is recommended that information regarding PS should be provided to patients and their caregivers repeatedly as early as possible. Existential suffering alone is not an indication for PS, and there is a lack of evidence on bispectral analysis. Additional research on PS is needed in Korea.

존엄사의 법제화와 완화의료

이지은(Lee, Ji eun) 숭실대학교 법학연구소 2015 法學論叢 Vol.34 No.-

우리나라에서 보라매 병원 사건, 김할머니 사건 등을 계기로 연명의료 중단에 관한 논의는 활발했음에 비해 연명의료와 병행되는 완화의료에 대해서는 존엄사와 관련된 논의가 상대적으로 적었던 것으로 보인다. 존엄한 죽음은 무의미하고 인공적인 연명의료를 강요하지 않는다는 의미 외에도, 죽음의 과정에서 수반되는 정신적 육체적 고통으로부터 인간의 존엄을 수호한다는 의미도 가진다. 그런데 법적으로 허용되는 존엄사의 범위를 소극적 안락사에 한정한다면, 생명 단축의 부작용을 가져오는 완화의료의 적법성이 필연적으로 문제된다. 또한 존엄사의 문제에 있어 환자의 자율성 존중을 강화하기 위한 법제도가 타당성을 갖기 위해서는 연명의료 절차에서 의사의 개입에 대한 명확한 기준이 제시되어야 한다. 그러므로 완화의료의 문제는 연명치료 중단의 문제와 밀접한 관련 속에서 논의되어야 할 것이며, 환자의 의사에 따른 연명의료 중단 이후 시행되는 진정제 투입 등의 처치를 법적 관점에서 어떻게 볼 것인가에 대한 해석이 반드시 필요하다. 프랑스는 존엄사에 대한 논의의 초기부터 완화의료를 환자의 권리로 인정하였고, ‘고통 없는 자연스러운 죽음’을 중심으로 존엄사의 법제화가 이루어졌으므로 프랑스의 존엄사법 제·개정 논의는 우리나라의 입법 과정에서 참고할 가치가 있다. 특히 최근까지 논란의 중심이 된 레오네티법 개정안, 소위 ‘숙면(熟眠)법안’의 진정치료를 완화의료의 허용범위와 관련하여 검토하고자 한다. The development of life-sustaining treatment such as inventing the respirator makes new legal controversies. The Case of “grandmother Kim" and ”Boramae Hospital“ sparked a discussion on the death with dignity. So the disscussion on the terminating meaningless life-sustaining has been agitated for years. But the problem on the treatment palliative care paralleled with life-sustaining treatment was neglected. The death with dignity means not only the refuse of artificial life-sustaining care, but also the defend of human’s dignity from the physical and emotional pain. So we must focus a discussion on whether the legality of the palliative care after terminating life-sustaining treatment could be legal or not, when it can have an effect on lifetime of patient. Because certain palliative care-for example, “terminal sedation” that provoked intense debate in the legislative procedure in France-coulde be considered as an active euthanasia. From the beginning of the discussion on the death with dignity, the palliative carewas recognized as the rights of patients in France. Therefore, it deserves consideration their legislative changes on the rights of death with dignity in France, speciailly on the “deep, and terminal sedation until death”.

호스피스ㆍ완화의료와 의사조력자살 간 경계에 관한 규범적 고찰

엄주희 ( Ju-hee Eom ),김명희 ( Myung-hee Kim ) 연세대학교 법학연구원 2018 法學硏究 Vol.28 No.2

Physician-Assisted-Suicide is a form of death that can be classified as a same category with Assisted Suicide, Assisted Dying and Aid in dying. Worldwide, such as US, Canada, Europe, Australia, laws on Physician-Assisted-Suicide have been enacted, or the justification of that has already been addressed through court precedents. Increasing awareness of rights and a movement to expand autonomy in all areas have led to claims and legalization of Physician-Assisted-Suicide in the last few decades. In Korea, the law on decision-making at the end of life about forgoing life sustaining treatment has been in force since 2018 as a single law with Hospice palliative care. In the implementation of Hospice palliative care especially, palliative sedation, there is controversy that the indirect effect of medical care can lead to hastening death, and in part, the appearance and method of sedation is similar to Physician-assisted-Suicide. Therefore, it should be noted that there has been controversy in claiming the legitimacy of Physician-Assisted-Suicide with the legitimacy logic of hospice palliative care in the case of foreign cases and legislation. By analyzing the differences between palliative sedation and Physician-Assisted-Suicide and the reason of legal justification, implications will be derived that can be applied to Korean legislation which made the first step on the legal medical decision-making system at the end of life.

말기 암환자에서 진정제 사용 실태 조사

안미홍,염창환,이혜리 대한가정의학회 2002 Korean Journal of Family Medicine Vol.23 No.4