Professional Documents
Culture Documents
T hese recommendations are in- tients of a “good death.” Just as develop- sion-making and the corresponding ac-
tended to provide information ments in knowledge and technology have tions, these guidelines will focus on the
and advice for clinicians who dramatically enhanced our ability to re- latter.
deliver end-of-life care in in- store patients to health, similar develop- These recommendations are written
tensive care units (ICUs). The number of ments now make it possible for almost all from the emerging perspective that pal-
deaths that occur in the ICU after the patients to have a death that is dignified liative care and intensive care are not
withdrawal of life support is increasing, and free from pain. mutually exclusive options but rather
with one recent survey finding that 90% The management of patients at the should be coexistent (12–14). All inten-
of patients who die in ICUs now do so end of life can be divided into two phases. sive care patients are at an increased risk
after a decision to limit therapy (1). Al- The first concerns the process of shared of mortality and can benefit from inclu-
though there is significant variability in decision-making that leads from the pur- sion of the principles of palliative care in
the frequency of withdrawal of life sup- suit of cure or recovery to the pursuit of their management. The degree to which
port both within countries (2) and among comfort and freedom from pain. The sec- treatments are focused on cure vs. palli-
cultures (3), the general trend is interna- ond concerns the actions that are taken ation depends on the clinical situation,
tional in scope (4). Nevertheless, most once this shift in goals has been made but in principle both are always present
evidence indicates that patients and fam- and focuses on both the humanistic and to some degree. Figure 1 illustrates a
ilies remain dissatisfied with the care technical skills that must be enlisted to useful paradigm for the integration of
they receive once a decision has been ensure that the needs of the patient and palliative care and curative care over the
made to withdraw life support (5). Al- family are met. Although both of these course of a patient’s illness.
though intensive care clinicians tradi- issues are critically important in end-of- Although many patients are best
tionally have seen their goals as curing life care, the decision-making process is served by transfer to other environments
disease and restoring health and func- not unique to the ICU environment and (e.g., home, hospice, or ward) that may
tion, these goals must now expand when has been addressed by others (6 –11). be more conducive to palliative care,
necessary to also include assuring pa- These recommendations, therefore, do some patients are so dependent on ICU
not deal primarily with the process that technology at the end of life that transfer
leads to the decision to forego life- is not possible. For those who are ex-
From the Ethics Committee, American College of prolonging treatments but rather focus pected to survive for only a short time
Critical Care Medicine. after the removal of life-sustaining tech-
The American College of Critical Care Medicine
on the implementation of that decision,
with particular emphasis on the ICU en- nology, transfer of the patient to a new
(ACCM), which honors individuals for their achieve-
ments and contributions to multidisciplinary critical vironment. environment with new caregivers is awk-
care medicine, is the consultative body of the Society This division of the process into two ward and may disrupt the patient’s med-
of Critical Care Medicine (SCCM) that possesses rec-
phases is necessarily somewhat artificial. ical care. For these reasons, among oth-
ognized expertise in the practice of critical care. The ers, intensive care clinicians must
ACCM has developed administrative guidelines and Patients and families do not suddenly
clinical practice parameters for the critical care prac- switch from the hope for survival and become as skilled and knowledgeable at
titioner. New guidelines and practice parameters are cure to the acceptance of death and pur- forgoing life-sustaining treatments as
continually developed, and current ones are system- suit of comfort. This process happens they are at delivering care aimed at sur-
atically reviewed and revised. vival and cure.
Supported, in part, by grants from the Argosy gradually over varying periods of time
Foundation and the Harvard Risk Management Foun- ranging from hours to weeks. Similarly,
dation. the forgoing of life-sustaining treatments Preparation of the Patient, the
Address requests for reprints to: Robert D. Truog, rarely happens all at once and is likewise
MD, Professor of Anaesthesia & Medical Ethics, Har- Family, and the Clinical Team
vard Medical School, Director, MICU, FA-108, Chil-
a stepwise process that parallels the shift
dren’s Hospital, Boston, MA 02115. in goals. Although acknowledging the re- As the decision to forego further use of
Copyright © 2001 by Lippincott Williams & Wilkins lationship between the process of deci- life-sustaining treatments is being made,
Typical Typical
Equianalgesic Starting Dose, Starting Dose, Duration, Typical Starting
Medication Dosing, IV Adult, IV Pediatric, IV hrs Infusion Rate Comments
Morphine 1 2–10 mg 0.1 mg/kg 3–4 0.05–0.1 mg䡠kg⫺1䡠hr⫺1 Histamine release (caution in
asthma), vasodilation,
hypotension
Hydromorphone 0.15 0.3–1.5 mg 3–4 Less pruritus, nausea, sedation, and
euphoria than morphine
Fentanyl 0.01 50–100 g 1–5 g/kg 0.5–2.0 1–10 g䡠kg⫺1䡠hr⫺1 Minimal hemodynamic effects,
duration of action short when
given by intermittent bolus, half-
life prolonged when administered
chronically
Meperidine 10 25–100 mg 1 mg/kg 2–4 Not recommended for chronic use;
catastrophic interaction with MAO
inhibitors; tachycardia; seizures
Typical Typical
Starting Dose, Starting Dose, Duration, Typical Starting Infusion Typical Starting Infusion
Medication Adult, IV Pediatric, IV hrs Rate, Adult Rate, Pediatric Comments
Lorazepam 1–3 mg 0.05 mg/kg 2–4 0.025–0.05 mg䡠kg⫺1䡠hr⫺1 0.05–0.1 mg䡠kg⫺1䡠hr⫺1 Longer acting, ideal for long-
term administration
⫺1 ⫺1
Midazolam 1 mg 0.1 mg/kg 1.5–2 1–5 mg/hr 0.05–0.1 mg䡠kg 䡠hr Well tolerated but fairly
expensive
Haloperidol 0.5–20 mg 2–4 3–5 mg/hr IV Not often used in pediatrics
because extrapyramidal
effects more frequent
Propofol 1 mg/kg 1 mg/kg 10–15min 0.5–3.0 mg䡠kg⫺1䡠hr⫺1 0.5–3.0 mg䡠kg⫺1䡠hr⫺1 Hypotension, lipid base lead to
hyperlipidemia, painful on
injection
Pentobarbital 150 mg 2–6 mg/kg 2–4 3–5 mg䡠kg⫺1䡠hr⫺1 3–5 mg䡠kg⫺1䡠hr⫺1 Propofol should replace
pentobarbital in most end-
of-life situations
IV, intravenous.
From Refs. 52, 59 – 65, 71.
hand, when a clinician administers 2 g of ing the withdrawal of life support (69). A pnea) and psychological (e.g., panic, anx-
morphine acutely to a patient who is not similar study performed in pediatric ICUs iety, fear). Assessment should include an
profoundly tolerant, it is difficult not to found an increase in diazepam equiva- investigation for potentially treatable
conclude that the clinician did intend the lents from 0.26 to 0.68 mg·kg⫺1·hr⫺1 and causes before focusing on symptom man-
death of the patient. an increase in morphine equivalents from agement. Symptom severity scales, such
The concept of “anticipatory dosing” 0.54 to 1.80 mg·kg⫺1·hr⫺1 during the as the modified Borg dyspnea scale and
(as opposed to reactive dosing) also withdrawal of ventilator support (70). In the Bizek agitation scale, can be used to
should guide clinicians in the use of se- addition, a review of 121 neonatal deaths assess symptoms associated with breath-
dation and analgesia at the end of life. reported that most patients (84%) re- lessness (29, 71–73).
The rapid withdrawal of mechanical ven- ceived analgesia as their life support was Treatment of dyspnea may include
tilation is an example of the need for withdrawn, and that most of these pa- pharmacologic and nonpharmacologic
anticipatory dosing. At the time of venti- tients (64%) could be managed with strategies. Simple positioning may be ef-
lator withdrawal, the clinician can antic- doses of morphine in the usual pharma- fective. Patients with chronic obstructive
ipate that there will be a sudden increase cologic range (0.1– 0.2 mg/kg intrave- pulmonary disease may be most comfort-
in dyspnea. It is not sufficient simply to nously). Infants who were tolerant to able sitting up or leaning over a bedside
respond to this distress with titrated morphine required larger doses, up to 1 table. Patients with unilateral lung dis-
doses of an opioid (reactive dosing). mg/kg intravenously. Of particular note, ease (e.g., pneumonia) may prefer lying
Rather, clinicians should anticipate this there was no relationship between the on one side more than the other.
sudden event and provide adequate med- dose of morphine used and the time until Pharmacologic approaches to dyspnea
ication beforehand (anticipatory dosing). death after ventilator withdrawal (42). are varied. Oxygen may enhance patient
As a general rule, the doses of medication Alleviation of Specific Symptoms. comfort by relieving hypoxemia (74).
that the patient has been receiving hourly Campbell (29) called attention to many of However, one study of advanced cancer
should be increased by two- or three-fold the specific symptoms that may be expe- patients reported that oxygen was no bet-
and administered acutely before with- rienced by terminally ill patients. Dys- ter than air in relieving dyspnea (75).
drawing mechanical ventilation. pnea is a form of suffering and is probably Sometimes patients experience symp-
There are some data on the use of the most important symptom that must tomatic relief by having air from a fan
sedatives and opioids during the with- be relieved for patients dying in the ICU. blowing gently on their face and may
drawal of life support. In one study, non- The incidence of this problem is not well have increased dyspnea from a feeling of
comatose adult patients received analge- described, but data suggest that it is claustrophobia associated with the ad-
sia and sedation during withdrawal of life present in up to half of dying persons ministration of oxygen by a facemask.
support, with an increase in benzodiaz- (29). Although dyspnea in patients dying Opioids relieve dyspnea by depressing re-
epine from a dose equivalent to 2.2 mg/hr of respiratory failure is almost always at- spiratory drive, producing sedation and
of diazepam to 9.8 mg/hr and an increase tributable to progression of their under- euphoria, and causing vasodilation,
in opioid from a dose equivalent to 3.3 lying disease, clinicians should remem- which can reduce pulmonary vascular
mg/hr of morphine to 11.2 mg/hr at the ber that the differential diagnosis for congestion. Patients also may benefit
time that life support was withdrawn dyspnea is extensive and includes many from the judicious use of bronchodilators
(68). A retrospective study of three adult potentially treatable conditions such as and diuretics to relieve small airway ob-
ICUs found that large doses of morphine reactive airway disease, infection, pneu- struction and pulmonary vascular con-
(mean, 21 ⫾ 33 mg/hr) and benzodiaz- mothorax, congestive heart failure, and gestion.
epines (equivalent to a mean diazepam anxiety. The response to this sensation is Nausea and vomiting are frequently
dose of 8.6 ⫾ 11 mg/hr) were given dur- both physiologic (e.g., tachycardia, tachy- reported at the end of life. As with dys-
R
tinue NMBAs during ventilator with- the patient is truly dependent on ventila-
drawal (121). tor support for survival. This is not al- ecommendations
NMBAs possess no sedative or analge- ways easy to do— 8% of “terminally
such as these can
sic activity and can provide no comfort to weaned” patients from one study survived
the patient when they are administered at to hospital discharge (93). If there is a only attempt to
the time of withdrawal of life support. small but significant chance that the pa-
Clinicians cannot plausibly maintain that tient could survive separation from the articulate practices that are
their intention in administering these ventilator in the absence of the neuro-
agents in these circumstances is to ben- muscular blockade, then the effects of the based on sound ethical rea-
efit the patient. Indeed, unless the patient blockade must be eliminated before ven- soning and that are conso-
is also treated with adequate sedation and tilator withdrawal.
analgesia, the NMBAs may mask the signs Second, clinicians must be aware that nant with current cultural
of acute air hunger associated with ven- neuromuscular blockade will signifi-
tilator withdrawal, leaving the patient to cantly impair their ability to assess the and legal norms.
endure the agony of suffocation in silence patient’s comfort. Paralyzed patients are
and isolation. Although it is true that unable to communicate any evidence of
families may be distressed while observ- discomfort or distress during the process
ing a dying family member, the best way of withdrawal of life support. Autonomic disease. In recent years, critical care prac-
to relieve their suffering is by reassuring signs such as hypertension and tachycar- titioners increasingly have recognized
them of the patient’s comfort through dia are highly unreliable. The onus is on that our obligations to patients extend
the use of adequate sedation and analge- the clinicians to use medications in dos- beyond our attempts to treat disease and
sia. ages sufficient to ensure the patient’s include a commitment to providing pa-
The same considerations apply to comfort despite the absence of the usual tients with a dignified and tolerable
most patients who are receiving NMBAs behavioral clues to the patient’s level of death.
at the time that the decision to withdraw distress. This is certainly possible (it is Meeting these obligations will require
life support is made. In most cases, the done routinely by anesthesiologists car- that intensive care clinicians learn how to
effect of these agents can be reversed or ing for pharmacologically paralyzed pa- operate within a new paradigm or model
allowed to wear off within a short period tients during anesthesia and surgery), of care. In the curative model, the “med-
of time, allowing for the withdrawal of but it does require sufficient knowledge, ical indications” for diagnostic and ther-
mechanical ventilation in the absence of skill, and experience on the part of the apeutic procedures are judged relevant to
the confounding effects of paralysis. As a ICU clinicians. the contribution they make toward cur-
general rule, therefore, pharmacologic Third, clinicians must balance the ing the patient. In the palliative model,
paralysis should be avoided at the end of costs of waiting until the NMBAs can be however, these indications are judged
life. reversed or wear off against the potential relative to symptom relief, improved
Patients who have been receiving benefits. In addition to removing uncer- functional status, or the amelioration of
NMBAs chronically for management of tainty about the prognosis and ensuring emotional, psychological, or spiritual
their ventilatory failure occasionally can the availability of behavioral clues about concerns. The former focuses on the
present a more difficult ethical dilemma. the patient’s comfort, waiting until neu- treatment of diseases, the latter on the
In some situations, restoration of neuro- romuscular function can be restored has treatment of symptoms.
muscular function may not be possible the theoretical benefit of allowing the pa- In this context, treatment of the pa-
for several days or even weeks, because of tient to interact with family members and tient’s pain often becomes the highest
relative overdosage of the drug or the other loved ones both before and during priority. The notion of pain as the fifth
accumulation of active metabolites (122). the process of withdrawing life support. vital sign is one way of signifying this
When faced with this problem, the clini- In summary, in certain cases of pro- importance. Critical care clinicians are in
cian must choose between withdrawal of longed paralysis, it may be reasonable to a unique position to affect this symptom.
the ventilator while the patient is para- proceed with removal of the ventilator Not only are we expert in delivering med-
lyzed vs. continuation of life support well provided the clinicians a) are highly cer- ications to relieve suffering, but we also
beyond the point at which the patient and tain that the patient could not survive can provide leadership that will enhance
family have determined that the burdens separation from the ventilator; b) proceed our ability to provide palliative care in
of such treatments outweigh the probable with careful regard for the patient’s com- ways that go beyond medications. We
benefits. In this circumstance, it may be fort; and c) have concluded that the ben- should work toward developing a culture
preferable to proceed with withdrawal of efits of waiting for the return of neuro- and physical environment in the ICU that
life support despite the continued pres- muscular function are not sufficient to enhance communication and facilitate
ence of neuromuscular blockade. This outweigh the burdens. the comfort of our patients.
recommendation is in accord with others Practical aspects of end-of-life care are
who have commented on this issue (34, Conclusions inseparably wed to many intensely con-
123–125). troversial ethical issues. Recommenda-
Before proceeding with the with- The early years of critical care medi- tions such as these can only attempt to
drawal of life support from a patient who cine were defined by remarkable discov- articulate practices that are based on
is pharmacologically paralyzed, several eries and innovations that dramatically sound ethical reasoning and that are con-
issues must be carefully considered. First, reduced the morbidity and mortality of sonant with current cultural and legal