Physicians' opinions on and practical experiences with palliative sedation therapy in children: an international survey in five European countries

Background: Palliative sedation therapy (PST) is used in the end of life (EOL) phase for terminally ill patients to alleviate refractory symptoms by lowering consciousness. This applies to both adults and children. No international comparative studies on the practice of paediatric PST exist, although such knowledge is needed for the development of guidelines and a broader discussion, including ethical aspects. Methods: An international retrospective cross-sectional survey in five European countries (Belgium, Czechia, Netherlands, Portugal, Switzerland) was performed. Questionnaires were distributed via email. Topics of the questionnaire concerned paediatric PST practices and opinions/attitudes about ethical discussion points. Data was analysed using descriptive analyses, chi-square-tests, and ANOVA tests. Results: Three hundred and forty-eight physicians completed the questionnaire (127 Belgium, 78 Czechia, 45 Netherlands, 57 Portugal, 21 Switzerland). 32% of respondents were specialized in general paediatrics. Most respondents use midazolam (85%) and opioids (78%) for PST. Parents are almost always involved in decision-making (93%), whereas competent children are involved to a lesser extent (77%). There is a greater agreement that refractory physical symptoms are an indication for PST (99%) than refractory psychological symptoms (69%). Most participants (63%) agreed to withdraw artificial hydration/nutrition in the last hours/days of life. Only 37% disagreed that PST shortens the dying process. We found significant differences in answers by country, speciality, workplace, experience and palliative care training. Conclusions: Nearly all of the 348 physicians across Belgium, Czechia, Netherlands, Portugal and Switzerland agreed that refractory physical symptoms are an indication for PST and, in practice, use midazolam and opioids most frequently. Variations exist in medication choices, decision-making processes, intentions for sedation, and attitudes towards ethical considerations. These findings suggest that educational, cultural, legal, and healthcare system differences shape the approach to palliative sedation.