Continuous deep sedation at the end of life of children in Flanders, Belgium

Context. Few guidelines have yet been put forth for continuous deep sedation
in pediatrics, and empirical data on the use of this practice in minors are rare.
Objectives. To estimate the incidence of continuous deep sedation in minor
patients (aged 1e17) and describe the characteristics of, and the decision-making
process before, continuous deep sedation.
Methods. An anonymous population-based postmortem survey was mailed to all
physicians signing the death certificates of all patients aged 1e17 years who died
between June 2007 and November 2008 in Flanders, Belgium. The questionnaire
concerned whether or not continuous deep sedation was used at the end of life
and measured characteristics of sedation and the decision-making process
preceding it.
Results. Response rate was 70.5% (n ¼ 165). Of all children, 21.8% had been
continuously and deeply sedated at the end of life. Duration of sedation was one
week or less in 72.4% of cases, and artificial nutrition and hydration were
administered until death in 54.3% of cases. Benzodiazepines were used as the sole
drug for sedation in 19.4% of cases, benzodiazepines combined with morphine in
50%, and morphine as the sole drug in 25%. In 23.5% of cases, physicians had the
explicit intention, or the concurrent intention, to hasten death. Only 3.0% of
patients requested sedation and 6.1% consented. Parents consented in 77.8% of
cases and requested sedation in 16.7%.
Conclusion. Minor patients were commonly kept in continuous deep sedation
or coma until death in Flanders, Belgium. Given the high incidence of the
practice and indications that it is often used without involving the patientdand
sometimes with a life-shortening intentiondthe development of specific
guidelines for sedation in children might contribute to due care practice.
J Pain Symptom Manage 2011;41:449e455.