The Vitals: A Good Death – Palliative Care in the ICU

As an aside, COVID-19 has really thrown a massive wrench in these end of life discussions. Many institutions and hospitals have strict visitor policies that prevent these conversations from happening face-to-face. While these policies are needed to prevent infection spread, it is absolutely brutal and devastating to have these conversations over the phone without the actual ability to connect with your patient’s family in person. This article is written from the perspective of being able to have a full face-to-face conversation with your patient’s family.

How you approach the next few steps after a family decides to transition to comfort measures will make a huge impact on you, your patient and their family, and your team. You, as the ICU physician or provider, have the ability to take away suffering, anxiety, air hunger, and pain at the end of life. Most institutions have their own protocols for “CMO orders” or comfort measure orders, which are a specific set of medications that include a mixture of opiates, benzodiazepines, antipsychotics, antiemetics, and antimuscarinics. These medications address pain, air hunger, anxiety, confusion, delirium, nausea, and excessive secretions at the end of life. These conditions can be distressing for patients, families, and the hospital staff caring for the patient.

There are also several non-medical issues to be aware of. For example: does your patient need a religious clergy-person available? Are there other members of the family that need to be here to say goodbye? Is there a particular artifact or item that the family wishes to have with the patient at the end of life?

It is important that you address all questions and concerns from the family. The most common question I get asked is “how long do you think it’ll take?” While there is no way to answer this question with certainty, you can make educated guesses. If your patient is on several pressors and maximal ventilatory support, they may not survive very long without the support.

Setting expectations about the dying process is crucial. I make it a point to explain all the medications I am ordering and what they are for, and how we will make sure that their loved one is without pain, discomfort, anxiety, or fear. I also try to warn them that they may hear gasping noises (death rattles), or see what appears to be gasping for air towards the end of life (Cheyne-Stokes respiration), but we will do our best to control those with medications.

One may raise concern that the opiates given may hasten death, however there is no good evidence that higher doses of opiates or sedatives are associated with precipitation of death. You, as the physician or provider, have an ethical obligation to treat your patient’s discomfort when comfort is the primary goal, even if it may hasten death. 

The majority of the patients who are transitioned to comfort measures are on some form of life support, whether that be mechanical ventilation or vasopressors (likely both). When the decision to transition the patient to comfort measures takes place, all medications or interventions that are not contributing directly to the patient’s comfort are discontinued. In terms of medications, this means discontinuing all medications that aren’t contributing to the patient’s direct comfort (antibiotics, antihypertensives, statins, aspirin, etc.). Vasopressor medications and mechanical ventilation are also discontinued, but there is some nuance here: I usually leave the vasoactive medications on board until the family is ready to start the process, and the patient has been adequately sedated and is about to be extubated; more on this below. 

Typically, I will start my patients on an opiate drip with PRN boluses of opiates every five minutes that the nurse can elect to give based on signs/symptoms of discomfort (difficulty breathing, grimacing, vocalizing pain, etc.). Opiates have been shown to significantly reduce symptomatic dyspnea at the end of life without causing opioid-induced respiratory depression. Medications I’ve seen used are hydromorphone, fentanyl, or morphine. Keep in mind that patients who are not opiate naive may need higher doses of medication that usual. If the patient is conscious and able to communicate their needs, then sometimes I will elect to use a PCA with a constant rate and bolus dose that the patient can control. Your institution should have guidelines on how to order and dose PCAs, so I’d recommend reading those.