paralytics in comfort care?

[error404]

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My aunt passed away in France today, after a long battle with several cancers. (Yes, several.)

My stepmother, a nurse, says that she suffered "from such extreme anxiety at the end that the doctors made the decision to paralyze her." She passed "peacefully" soon after. She was also on a morphine drip.

To me, this doesn't make any sense at all. Did my stepmother leave out the part where they intubated and ventillated her? (She wasn't there herself.) Even so, has anyone HEARD of paralytics for comfort care? Wouldn't a benzo drip have made a lot more sense?

Paralytics are pretty crappy for anxiety... and when they say "peacefully," do they mean, "only screaming on the inside?"

I'm confused whether this is a big misunderstanding or if something really odd is happening in end of life care.

[I know this isn't entirely related to anesthesia, but I'm anesthesia, and this board is active.]

~error404

 

[dhb]

Paralytics are great drugs to kill someone not the best for it to happen peacefully. I highly doubt the paralytic would be used as the sole agent in this scenario.
I don't even think euthanasia is legal in France...

 

[Bertelman]

My aunt passed away in France today, after a long battle with several cancers. (Yes, several.)

My stepmother, a nurse, says that she suffered "from such extreme anxiety at the end that the doctors made the decision to paralyze her." She passed "peacefully" soon after. She was also on a morphine drip.

To me, this doesn't make any sense at all. Did my stepmother leave out the part where they intubated and ventillated her? (She wasn't there herself.) Even so, has anyone HEARD of paralytics for comfort care? Wouldn't a benzo drip have made a lot more sense?

Paralytics are pretty crappy for anxiety... and when they say "peacefully," do they mean, "only screaming on the inside?"

I'm confused whether this is a big misunderstanding or if something really odd is happening in end of life care.

[I know this isn't entirely related to anesthesia, but I'm anesthesia, and this board is active.]

~error404

I highly doubt she was paralyzed. Sedated, yes. I think your stepmom is getting third-hand info, and poor info at that.

 

[doctor712]

I just finished a Biomedical Ethics class, Europe does things a bit differently there; I recall that the Netherlands and some other countries do have very liberal euthanasia laws, indeed permitting euthanasia. Where it actually in fact legal. I think the Netherlands was the first of the European countries to ok this. There are two states in the US where it's doable, I think, as well. As per my memory though, the European laws (and the two US states) allow for purchase of a lethal medication after stringent steps are followed and a script is written. I will research France more if you'd like...

As an outsider, I agree, paralytics don't seem to fit the euthanasia bill. Perhaps medical records will ease the concern...?

Sorry to hear about your Aunt.

D712

 

[geogil]

Physician assisted suicide is legal in Oregon. As I recall you can ask the physician to prescribe a lethal dose and then you go home and take it on your own. Not quite the same as ol' Kevorkian holding the mask to your face, but still not somewhere that I'm willing to tread when I'm out practicing.

 

[Noyac]

Your stepmother is a nurse.

Need I say more?

 

[Intensivist]

Your stepmother is a nurse.

Need I say more?

😉

 

[dhb]

Your stepmother is a nurse.

Need I say more?

 

[Voodoo]

and you're a resident. You should know better.

 

[error404]

So, instead of entering into what could possibly be an interesting conversation, we've made it into insulting my stepmother and making light of my family tragedy?

I mentioned that she's a nurse because she's worked around paralytics (ICU) and has more insight than the average family member. Now, I hate nurses as much as the next doc who's gone through intern year, but redirect here.

Does anyone actually think there's ANY chance paralytics are being used in comfort care ANYWHERE?

 

[pgg]

Does anyone actually think there's ANY chance paralytics are being used in comfort care ANYWHERE?

No.

 

[Licoricestick]

Does anyone actually think there's ANY chance paralytics are being used in comfort care ANYWHERE?

No - why would you do this to someone, there is no comfort in being paralysed and in any way aware. And "comfort care" generally doesn't mean an ICU admission for intubation and mechanical ventilation (without it muscle relaxants are murder - at least in this country).

They may be being used for euthanasia in counties where that is legal - but euthanasia is euthanasia, not comfort care.

 

[doctor712]

So, instead of entering into what could possibly be an interesting conversation, we've made it into insulting my stepmother and making light of my family tragedy?

I mentioned that she's a nurse because she's worked around paralytics (ICU) and has more insight than the average family member. Now, I hate nurses as much as the next doc who's gone through intern year, but redirect here.

Does anyone actually think there's ANY chance paralytics are being used in comfort care ANYWHERE?

I already answered earnestly, but to follow up, (grain of salt from me, I know) i CAN imagine some Doc mumbling something like, "because she wasn't comfortable....we paralyzed her, mumble mumble, and then....mumble mumble....french french, english, english....intubated, put her to sleep...mumble...and she passed shortly after paralyzing, ya know..." and THE ONLY PART that got passed along in the chaos/translation/moment was, "we paralyzed her..."

it just doesn't make ANY sense otherwise, does it? not here, not in oregon, and not in france or fiji...

D712

 

[painroddin]

The paralysis probably wasn't used to make her comfortable but to facilitate mechanical ventilation as many times patients toward the end have such bad acidosis and require a high minute ventilation due to sepsis/extravasation of bowel contents and tense belly or whatever the situation is that the patient can't compensate and be on benzos and opiates only. Someone breathing spontaneously more than about 35 -40 times even with good pressure support eventually starts breathing discontinously with the vent (bucking). I used to use occasionally 2-3 times/week in the unit. Simply put the morphine is and benzos are for the comfort, the paralysis was to probably gain mild benefit with the ventilator.

 

[doctor712]

Duly noted. My faux-quote was more suggesting paralytic for 'overall control of the situation', not comfort for patient by way of paralysis. But, I love reading explanations like this, so thanks as an aside. It just gets me googling terms more while I pretend like I have a chance at falling asleep soon.

I do hope the gist of my post remains that I think some of the picture, when conveyed to the OP, was most likely lost in the moment...

D712

 

[Licoricestick]

The paralysis probably wasn't used to make her comfortable but to facilitate mechanical ventilation as many times patients toward the end have such bad acidosis and require a high minute ventilation due to sepsis/extravasation of bowel contents and tense belly or whatever the situation is that the patient can't compensate and be on benzos and opiates only. Someone breathing spontaneously more than about 35 -40 times even with good pressure support eventually starts breathing discontinously with the vent (bucking). I used to use occasionally 2-3 times/week in the unit. Simply put the morphine is and benzos are for the comfort, the paralysis was to probably gain mild benefit with the ventilator.

Seeing as opioids, benzos, propofol etc etc are all respiratory depressants and if someone is already I+V in ICU but is for comfort care, then it doesn't matter what the pH/paCO2/paO2 is, so just give more - eventually they won't breathe over the ventilator.

Maybe I'm coming from a different perspective, because were someone already in ICU and tubed (which would be difficult to achieve with multiple malignancies that were presumable known to be life limiting) but then a decision was made for comfort care, we'd be looking at withdrawal of treatment, including extubation.

 

[midazme]

first, my condolences on your family's loss.

second, i also agree that paralytics aren't likely to be used for comfort care measures. in fact, in baby miller, they explicitly state that NMBDs 'lack analgesic or anesthetic effects and must not be used to render an inadequately anesthesized patient paralyzed'. (that's a direct quote, bitches. 😉)

third, i have yet to see any patient in the ICU be paralyzed. it interferes with neuro exams, SBTs, sedation vacations, and in general doesn't seem like a good idea unless you have a patient who is really fighting the vent AND for whom long-term ventilation is the only option. it doesn't seem like your aunt fit into this category, especially (as others have pointed out), comfort-care measures would include extubation and a peaceful, hopefully rapid, transition.

regards,
midazme.