"Palliative Syringe Driver"? A Mixed-Methods Study in Different Hospital Departments on Continuous Infusions of Sedatives and/or Opioids in End-of-Life Care

Objectives Continuous infusions of sedatives and/or opioids (continuous infusions) are frequently used in end-of-life care. Available data indicate challenges in nonspecialist palliative care settings. We aimed to assess the use of continuous infusions during the last week of life in different hospital departments. Methods In a sequential mixed-methods design, a retrospective cohort study was followed by consecutive qualitative interviews in 5 German hospital departments. Medical records of 517 patients who died from January 2015 to December 2017 were used, and 25 interviews with physicians and nurses were conducted. Recorded sedatives were those recommended in guidelines for "palliative sedation": benzodiazepines, levomepromazine, haloperidol (>= 5 mg/d), and propofol. Exploratory statistical analysis (R 3.6.1.) and framework analysis of interviews (MAXQDA 2018.2) were performed. Results During the last week of life, 359 of 517 deceased patients (69%) received continuous infusions. Some interviewees reported that continuous infusions are a kind of standard procedure for "palliative" patients. According to our interviewees' views, equating palliative care with continuous infusion therapy, insufficient experience regarding symptom control, and fewer care needs may contribute to this approach. In addition, interviewees reported that continuous infusions may be seen as an "overall-concept" for multiple symptoms. Medical record review demonstrated lack of a documented indication for 80 of 359 patients (22%). Some nurses experienced concerns or hesitations among physicians regarding the prescription of continuous infusions. Conclusions Continuous infusions seem to be common practice. Lack of documented indications and concerns regarding the handling and perception of a "standard procedure" in these highly individual care situations emphasize the need for further exploration and support to ensure high quality of care.