Palliative sedation/analgesia in end of life care

[Nephro critical care]

I have recently started using morphine drips more in end of life care. Previously I used morphine PRN pushes for discomfort. Now I use a gtt with a starting dose of about 4 mg / hr and then titrate for comfort. I worry about causing respiratory depression with higher doses as I am uncomfortable with the thought that I may be hastening the patient’s death but I want the patient to pass peacefully and not have the family watch the patient struggling. I am curious as to the regimens others use in end of life care.

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[jdh71]

I have recently started using morphine drips more in end of life care. Previously I used morphine PRN pushes for discomfort. Now I use a gtt with a starting dose of about 4 mg / hr and then titrate for comfort. I worry about causing respiratory depression with higher doses as I am uncomfortable with the thought that I may be hastening the patient’s death but I want the patient to pass peacefully and not have the family watch the patient struggling. I am curious as to the regimens others use in end of life care.

You are causing respiratory depression with the morphine in a dying patient regardless though. It’s a secondary effect of treating discomfort (pain or dyspnea).

 

[Hernandez]

I’d not call what you’re talking about palliative sedation, most articles I read about palliative sedation are for those in so much pain that you purposefully induce sedation as there is no other way to alleviated suffering. I’ve never had a situation which called for that but there are times that I’m sure it’s necessary.

I was doing some Locum at a decent sized hospital not long back and the nurses where down right thankful that I was being giving meds up front. The stories they told of what they’re docs typically does is not something I’d be ok doing to my dog much less a family member. Resp depression is going to happen, you just have to make your peace that you’re alleviating suffering so families don’t have to see that and come to ethical peace about it....or not

 

[dpmd]

You would probably be very uncomfortable with the way my nurses would handle things for terminal extubation (bolus of versed and fentanyl prior to extubation) on my patients. Followed by a morphine drip titrated to maintain comfort as evidenced by hr, BP, and resps within specific parameter to avoid issue with nurses who shared your discomfort at possibly hastening death and wouldn't titrate up unless the patient actually spoke up or similar. I often added a scopalamine patch to reduce secretions so the noisy resps that bother the family so much.

 

[deleted547339]

You would probably be very uncomfortable with the way my nurses would handle things for terminal extubation (bolus of versed and fentanyl prior to extubation) on my patients. Followed by a morphine drip titrated to maintain comfort as evidenced by hr, BP, and resps within specific parameter to avoid issue with nurses who shared your discomfort at possibly hastening death and wouldn't titrate up unless the patient actually spoke up or similar. I often added a scopalamine patch to reduce secretions so the noisy resps that bother the family so much.

Why fentanyl, not a morphine bolus?

 

[dpmd]

Why fentanyl, not a morphine bolus?

Because they were on fentanyl and versed drips prior to getting changed to comfort care. This way the nurses could do it without a separate order. Worked out nicely in the event the doctor only ordered small dose morphine pushes or some other inadequate comfort meds (but then we can get in the weeds on whether they ought to be doing that since it wasn't what those docs would like or whatever, but my ethics would be comfortable with something closer to what we do for sick animals than what the law allows right now-or what other docs feel comfortable with-as long as the patient or family is on board so I am not the best judge on this)

 

[deleted547339]

Because they were on fentanyl and versed drips prior to getting changed to comfort care. This way the nurses could do it without a separate order. Worked out nicely in the event the doctor only ordered small dose morphine pushes or some other inadequate comfort meds (but then we can get in the weeds on whether they ought to be doing that since it wasn't what those docs would like or whatever, but my ethics would be comfortable with something closer to what we do for sick animals than what the law allows right now-or what other docs feel comfortable with-as long as the patient or family is on board so I am not the best judge on this)

I always tell the nurse that if they ever think the patient needs more pain meds or anxiolytics to give them then let me know, in that order.

 

[dpmd]

I always tell the nurse that if they ever think the patient needs more pain meds or anxiolytics to give them then let me know, in that order.

It was always heartbreaking for me to see the family suffer longer than necessary. If the patient lasted long enough to get downgraded to the floor on comfort care I felt I failed the patient and the family. Mostly because I knew those nurses were way too busy to really watch the patient carefully and ensure minimal suffering (and there they were much more likely to balk at medicating because of being afraid for their license because the dosages might get crazy high). I had my specific nurses who were on my same wavelength and tried to have them take care of my comfort care patients as much as possible. It is harder and easier now that I don't own any of my critical patients (closed unit here) so I either decide they need an operation or not and them my role is much less involved (though I can be slightly active by calling palliative care and telling the patients or family what I think about prognosis). Harder because occasionally i see stuff being done i don't agree with but easier because i can walk away and not keep seeing it.

 

[Nephro critical care]

I see that when a patient/family has decided to move to comfort measures; once the family has said their goodbyes they want the patient to pass away soon within an hour or so. And if he/she is hanging on they become restless and start asking when the patient will die. Sometimes this is because of factors that can be selfish but still true like they have already taken many days off from work/their children and need to get back to them. Sometimes family is visiting from out of state and can only be there for a couple of days and want to present at the funeral. An elderly patient’s wife/husband will have all the time for their dying loved one but children/extended family have to get back to their regular lives.
That makes me think why as health care providers we are so uncomfortable about hastening death. I am sure if you were able to ask the patient on every occasion what he would want once all hope of a quality life is lost he would want a quick / painless end rather than a lingering painful death. The laws needs to change for 48 states of the United States. Oregon and Washington have it right. Death with Dignity.

 

[Nephro critical care]

I misspoke. Now California, Colorado, District of Columbia, Hawaii, Montana, New Jersey, Oregon, Vermont and Washington have physician assisted dying laws.

 

[dpmd]

I misspoke. Now California, Colorado, District of Columbia, Hawaii, Montana, New Jersey, Oregon, Vermont and Washington have physician assisted dying laws.

I was consulted on a guy for a surgical issue that was interested in this. Apparently it isn't so straightforward even though the forms are pretty self explanatory. The preferred med is supposedly several thousand dollars. But just the fact I told him I would figure it out with him let him get comfortable enough that he was willing to accept hospice care and at the end he didn't need my help.

The fact my hospital is religious and doesn't want us offering this to patients was a secondary issue since I don't let what they want affect what I say and if the patient went through with it we would have done so out of my office which is not affiliated with the hospital. But they have been buying up practices in town which means those docs employed by the foundation would risk their jobs if they offered it.

 

[Hamhock]

Are we (physicians) ready to commit to medically-directed end-of-life, if directed by the patient?

I am!

HH

 

[jdh71]

The line is fine and nuanced but I’m not ready to start putting people down like animals.

 

[sluggs]

In the last year, I have had 2 patients with advanced ALS who had weakness to the point where they were intubated (neither by me) in fits of panicked rapid shallow breathing. I saw no hope for either, and with their families' understanding, I had to extubatne them to comfort care on propofol (morphine alone not enough to insure comfort). Certainly a fine nuanced line as JDH says, but I saw no humane alternative.

 

[deleted171991]

I have recently started using morphine drips more in end of life care. Previously I used morphine PRN pushes for discomfort. Now I use a gtt with a starting dose of about 4 mg / hr and then titrate for comfort. I worry about causing respiratory depression with higher doses as I am uncomfortable with the thought that I may be hastening the patient’s death but I want the patient to pass peacefully and not have the family watch the patient struggling. I am curious as to the regimens others use in end of life care.

There is a very smart and common sense explanation of the process in the excellent Clinical Practice Manual for Pulmonary and Critical Care Medicine by Dr. Landsberg (at the end of the book, Compassionate Terminal Extubation):

"Start a combination of narcotic and benzodiazepine drips, while the patient is on full support. For example, Morphine and Ativan, both at 5 mg/hr (at least)

After sedation takes effect, the patient should be placed on pressure support (PS) 0/0

If this sudden lack of ventilator support produces an increased work of breathing, the patient should be place back on mechanical ventilation and both sedatives should be increased by 2-5 mg/hr, and given time to take effect (20-30 min)

Medication increase is followed by PS 0/0 trial, and the cycle is repeated until PS 0/0 is tolerated without causing an increase in respiratory effort

At this point the patient can be easily extubated to room air

Post-extubation oxygen support provides no significant comfort, in this situation, and may needlessly delay death)"

This way one is titrating to comfort, not hastening death (beyond what comfort care itself does). As long as one focuses on patient comfort and titrates medications to that (meaning one goes slow, no crazy boluses like the genius who pushed 500 mcg of fentanyl in a kid), one should be within the Law. Always protect yourself first!

The other important thing is not to let the family stimulate the patient post-extubation. They should treat him as if he's sleeping and should not be woken up. No last words, goodbyes, etc., just a quiet vigil.

If your ICU doesn't have a protocol for this, you guys should sit down and write one, with the nurses, and then make it into a nursing protocol.