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Published Online: 8 May 2014

Palliative Sedation Therapy: A Systematic Literature Review and Critical Appraisal of Available Guidance on Indication and Decision Making

Publication: Journal of Palliative Medicine
Volume 17, Issue Number 5


Background: Palliative sedation therapy (PST) is increasingly used in end-of-life care. However, consensus about definitions, indications, and treatment decision making is lacking.
Objective: The objective is to review and critically appraise published guidelines on indication and decision making for PST.
Methods: Data sources are CINAHL, Cochrane Library, EMBASE, PsycINFO, PubMed, and references of included papers through February 2013. Selection criteria were that papers included a PST guideline and were written in English or German. The term “guideline” was defined according to MEDLINE. Two investigators extracted information on the guidelines' recommendations on indication and decision making.
Results: The nine eligible guidelines differ in their definitions of PST. In addition key terms such as “refractory symptom” or “intolerable suffering” are used differently. These criteria are also weighed differently in their relevance for indication and decision making. PST for psychological distress is regarded as exceptional by eight guidelines, but only two guidelines provide reasons for this exceptionalism in comparison with PST for somatic suffering. In the majority of guidelines the role of different stakeholders involved in decision making is not specified. With regards to the limitation of life-sustaining measures, e.g., intravenous hydration, in the context of PST the analyzed guidelines differ in their recommendations.
Conclusions: PST guidelines differ considerably on aspects of indication and decision making about PST which are relevant from a clinical as well as ethical perspective. The comparison and critical appraisal can serve as a starting point for the improvement of future PST policies.

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Appendix 1: PRISMA 2009Checklist
Section/topic#Checklist itemReported on page #
Title1Identify the report as a systematic review, meta-analysis, or both.1
Structured summary2Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.2
Rationale3Describe the rationale for the review in the context of what is already known.3
Objectives4Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).3, 4
Protocol and registration5Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.4
Eligibility criteria6Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.4
Information sources7Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.4
Search8Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.4
Study selection9State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).4
Data collection process10Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.4
Data items11List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.4, Table 1
Risk of bias in individual studies12Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.Not applicable
Summary measures13State the principal summary measures (e.g., risk ratio, difference in means).Not applicable
Synthesis of results14Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I2) for each meta-analysis.Not applicable
Risk of bias across studies15Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).Not applicable
Additional analyses16Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.Not applicable
Study selection17Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.5, Fig. 1
Study characteristics18For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.5, Table 1
Risk of bias within studies19Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12).Not applicable
Results of individual studies20For all outcomes considered (benefits or harms), present for each study: (1) simple summary data for each intervention group and (2) effect estimates and confidence intervals, ideally with a forest plot.5–7; Table 1
Synthesis of results21Present results of each meta-analysis done, including confidence intervals and measures of consistency.Not applicable
Risk of bias across studies22Present results of any assessment of risk of bias across studies (see Item 15).Not applicable
Additional analysis23Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]).Not applicable
Summary of evidence24Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., health care providers, users, and policy makers).9–13
Limitations25Discuss limitations at study and outcome level (e.g., risk of bias), and at review level (e.g., incomplete retrieval of identified research, reporting bias).13
Conclusions26Provide a general interpretation of the results in the context of other evidence, and implications for future research.13
Funding27Describe sources of funding for systematic review and other support (e.g., supply of data); role of funders for the systematic review.13
Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group: Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 2009;6:e1000097.
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Published In

cover image Journal of Palliative Medicine
Journal of Palliative Medicine
Volume 17Issue Number 5May 2014
Pages: 601 - 611
PubMed: 24809466


Published online: 8 May 2014
Published in print: May 2014
Accepted: 3 January 2014


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Eva Schildmann
Department of Palliative Medicine, Munich University Hospital, Munich, Germany.
Jan Schildmann
Institute for Medical Ethics and History of Medicine, Ruhr-University Bochum, Germany.


Address correspondence to:Jan Schildmann, MAInstitute for Medical Ethics and History of MedicineRuhr-Universitaet BochumMalakowturm-Markstraße 258aD-44799 BochumGermany
E-mail: [email protected]

Author Disclosure Statement

Jan Schildmann is head of the NRW Junior Research Group “Medical Ethics at the End of Life: Norm and Empiricism” at the Institute for Medical Ethics and History of Medicine, Ruhr-University Bochum, which is funded by the Ministry for Innovation, Science and Research of the German state of North Rhine-Westphalia. The funders played no role in study design, collection, analysis, interpretation of data, writing of the report, or in the decision to submit the paper for publication. They accept no responsibility for the contents.

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