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Continuous palliative sedation until death: practice after introduction of the Dutch national guideline
  1. Siebe J Swart1,2,
  2. Agnes van der Heide1,
  3. Tijn Brinkkemper3,4,
  4. Lia van Zuylen5,
  5. Roberto Perez3,4,6 and
  6. Judith Rietjens1
  1. 1Department of Public Health, Erasmus MC, Rotterdam
  2. 2Nursing home Laurens Antonius IJsselmonde, Rotterdam
  3. 3Department of Anaesthesiology, VU University Medical Center, Amsterdam
  4. 4EMGO Institute for Health and Care Research (EMGO+), VU University Medical Center, Amsterdam
  5. 5Department of Medical Oncology, Erasmus MC Rotterdam
  6. 6Hospice Kuria, Amsterdam
  1. Correspondence to Siebe J Swart, Erasmus MC, Department of Public Health, Erasmus MC, Postbus 2040, Rotterdam 3000CA, The Netherlands; s.swart{at}


Background In 2005, a national palliative guideline was launched in The Netherlands. The authors describe the practice of continuous palliative sedation until death (CPS) after the introduction of this guideline.

Methods In 2008, a random sample of physicians (n=1580) were asked to fill out a questionnaire regarding the last patient in whom they had provided CPS until death.

Results The response was 38%. In all, 82% of the respondents were aware of the existence of the national guideline. Dyspnoea, pain and physical exhaustion were most often mentioned as decisive indications for continuous sedation. The decision to use sedation was discussed with all competent patients, but in 18% this merely involved informing the patient. Life expectancy at the start of continuous sedation was estimated to be less than 2 weeks in 97% of the cases. In 14%, the physicians had felt pressure to start the sedation, predominantly from patients and relatives. Physicians were present at the start of the sedation in 81% of the cases. Midazolam was used to induce the sedation in 92%. Overall, 41% of the physicians estimated that continuous sedation had hastened death to some extent. Most physicians thought that patients' complaints were adequately relieved by continuous sedation, that relatives were satisfied and that a good quality of dying was achieved.

Interpretation Continuous palliative sedation practice in The Netherlands largely reflects the recommendations from the national guideline. Issues needing further attention are the pressure felt by physicians to start continuous sedation and the potential life-shortening effect as mentioned by the physicians.

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  • Funding This study was made possible by a grant of the ZonMw and received additional funding from Sint Laurens Fonds Rotterdam, Stichting Palliatieve Zorg Dirksland-Calando and the Hospice Kuria. The funding sources were not involved in the conduct of the study or the development of the submission.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement JACR, AH, LZ and RSGMP designed the study. SJS and TB collected the data. SJS, TB, JR, RSGMP and AH had full access to all of the data in the study and take responsibility for the integrity of the data. SJS and JR analysed the data. SJS wrote the paper. The paper was critically read and commented by all authors who approved this article.