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Northeast Florida Medicine
Vol. 67, No. 1 2016
35
Palliative Care
some degree of prognostic ambiguity. Studies have shown
that patients who are on vasopressors and on a fraction of
inspired oxygen (FiO2) of over 70 percent tend to pass away
more quickly compared to those who are on a neurological
or neurosurgical service.
3
Extubation in Various Clinical Settings
About 20 percent of all deaths in this country occur in the
ICU. That is approximately 540,000 Americans that die in
the intensive care unit every year.
4
It follows that the ICU
is the most frequent setting that palliative care physicians
are called upon for compassionate terminal weaning. ICU
nurses, who are experienced in looking after critically ill
patients, are invaluable in the process. In fact, they often
take the initiative and are responsible for triggering a consult
for palliative care, as are the nursing case managers. Before
writing any orders to compassionately extubate the patient,
most ICUs mandate that two physicians document in the
chart that extubation of the patient is medically appropriate
under those specific clinical circumstances.
There is no therapeutic rationale for the use of neu-
romuscular blocking agents in the treatment of dying
patients during withdrawal of ventilation. They only pro-
duce the appearance of comfort and may be responsible
for the deliberate termination of life because of the effect
of iatrogenic neuromuscular blockage in the absence of
mechanical ventilation.
5
Two methods for ventilator withdrawal have been de-
scribed: immediate extubation or terminal weaning over a
period of 20 to 40minutes, gradually reducing the ventilator
rate and positive end-expiratory pressure (PEEP). Gradual
weaning gives the family more time to bid farewell, which
is a cathartic experience. Lest one thinks that this time is
marred by fear and discomfort, there is sometimes love
and laughter involved as the family members reminisce
about the good times and say their goodbyes. Children are
sometimes allowed in the roomwith their parents’ approval.
This is especially true if the terminal wean is being done
in the home setting.
6
When the ventilation rate and positive end-expiratory
pressure (PEEP) is at zero, the endotracheal tube cuff is
deflated. The tube is removed and oxygen is administered
by nasal cannula. Removing the tube helps to normalize
the patient and allows the family to get closer to the pa-
tient, both physically and emotionally. Patient comfort
is of paramount importance. Throughout the process the
focus is on making sure the patient remains asymptomatic.
There is nothing more hurtful to the family than seeing
their loved one suffer in pain or from air hunger- an image
they will carry with themselves for the rest of their lives.
Prior to the wean, patients can be premedicated with
glyccopyrrolate (Robinul) to help reduce pharyngeal secre-
tions, an analgesic, which could be morphine or hydromor-
phone (Dilauid), and a benzodiazepine, such as lorazepam
(Ativan) or midazolam (Versed). The dosages used depend
on whether the patient is opioid naïve and if they have
been on sedatives.
7
A good starting point in opioid naïve
patients is morphine 5 to 10 mg or hydromorphone 1 to
2 mg. These doses can be repeated at intervals of 10 to 20
minutes, as required for patient comfort. Ativan can be
started at 1 to 2 mg and can be repeated at similar intervals
as necessary. A nurse stands by with the syringes loaded to
be given immediately when requested by the physician. In
the ICU setting, the patients are often on an IV infusion of
fentanyl, diprivan (Propofol) or midazolam. Haloperidol,
2 to 4 mg can be given, as necessary, for any agitation that
may occur, at an interval of two to four hours.
With regard to specific dosing of the drugs, the concept
of “anticipatory dosing” (as opposed to reactive dosing)
should guide clinicians in the use of sedation and analge-
sia at the end of life. It makes rational sense to err on the
side of giving more medication producing sedation, rather
than administering the smallest possible dose to obviate