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36 Vol. 67, No. 1 2016 Northeast Florida Medicine DCMS online . org
Palliative Care
symptoms.8 Concerns about unintended consequences,
such as hastening death, are exaggerated, if established
dosing guidelines are followed.8 For those who believe
this might border on euthanasia, the ethical principle of
“double effect” should reassure the clinician. As long as the
intent of administering these drugs is not to hasten death
but for the benefit of the patient, the clinician is covered
from an ethical perspective.9 Studies have shown that higher
doses of opioids and benzodiazepines in the setting of life
sustaining treatment were not associated with hastening
death. In fact, the reverse is true.10
The route of drug administration is usually intravenous.
In certain instances, such as in the home setting or when IV
access is difficult, the subcutaneous route for medications
(morphine, hydromorphone, lorazepamand glycopyrrolate)
works just as well. The dosing intravenously is the same
as subcutaneously.
Prior to proceeding with extubation, the hospital bed
can be converted to a hospice bed. There are some finan-
cial and statistical implications for the institution, but
more importantly, this allows the family to receive the
benefits of bereavement counselling for up to a year after
the patient’s demise. This is especially true when children
are involved in the grieving process. It is at this time that
monitor alarms are silenced.
A member of the clergy is usually present unless the
family declines. Sometimes the patient and family are more
comfortable with having their own pastor attend and their
presence can be reassuring, not only for the family, but
also for members of the clinical team. Once the patient has
been extubated, the clinical teamwithdraws from the room
to give the family privacy to spend some final moments
with their loved one.
The clinician should be ready to spend additional time
with the family after the patient is extubated to address
their concerns, especially when they are second guessing
themselves about making the right decision. This is more
likely to happen when the whole dying process lasts longer
than anticipated. In such instances, it is the obligation of the
clinician to reassure the family about doing the “right thing.”
Conclusion
It is sometimes said that the most compassionate ex-
tubation is not intubating the patient in the first place.11
However, it is clearly not possible to predict with precision
which patients will progress to a compassionate terminal
wean.What is crucial is that withdrawing life support (ven-
tilator) should not be perceived by the patient or family as
withdrawing of care.12 Frequent and candid communication
with the family will obviate this issue. The patient needs
to continue to receive aggressive, timely and appropriate
palliative care. The role of the palliative care physician is to
facilitate the continuity of care from the curative mode to
one of comfort care, thereby reducing pain and suffering.
Palliative medicine is at the forefront of promoting
progressive and compassionate clinical practices for the
terminally ill patient which can, in fact, be very satisfying
for the physician. v
References
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