In our previous article, we discussed the SPIKES protocol and how to adapt it to ICU-specific end of life discussions. In this article, I would like to explore how we take our discussion with a patient and their families and translate that into action. Like everything in the ICU, a “good death” involves communication between the patient (if able), the family, the nurse, the RT, and the physician.
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.
For anxiety, the benzodiazepine I typically use is lorazepam. I’ll order 1mg every 30 minutes as needed for anxiety. Haloperidol for anxiety, agitation, or delirium is also typically used (2-5 mg IV). For nausea, I will also keep a PRN order for 4mg IV ondansetron every 6 hours ordered. 10mg IV metoclopramide can also work well for nausea, and has a shorter onset of action (1-3 min vs 30 min for ondansetron). For patients who are intubated, secretions are often an issue, especially when extubating. Typically, I’ll order glycopyrrolate or a scopolamine patch for these patients to help dry their secretions up. This will help with the “death rattle” that can often be heard, which can be very distressing for patient families.
In the ICU, more often than not, you will do terminal extubations on patients requiring vasopressor support. Prior to extubation, I’ll ask the patient’s nurse to start the comfort drips and make sure that the patient is comfortable. I’ll also ask for a dose of glycopyrrolate to be given prior to the extubation. I will try to terminally wean patients, especially if their main pathology was pulmonary/ARDS. This can be a longer process, but I’ll put my patient on a pressure support mode and gradually wean the PEEP and FiO2 to 5/40%. During the wean, I’ll ask the RN to titrate the opiates while assessing the patient’s breathing. After the wean, you’ll know that your patient is comfortable and not displaying signs of respiratory distress. At this time, you may terminally extubate the patient. The RT should be involved in this whole process, and should have their own method of terminally extubating. Common aspects include turning the ventilator alarms off, draping the patient with pads to catch any secretions, and having suction ready for any secretions or blood. I also ask the nurse to turn off all monitors in the room and alarms on the telemetry.
After the patient is terminally extubated, I will make sure that the patient looks comfortable and doesn’t have any more obvious needs. I will talk to the family, and let them know that I am available for whatever they need, and make sure their immediate needs are met (did the clergy-person come, do they need any food/drink, etc.). I then will huddle with the RT and RN and make sure there are no medications that have not been ordered or miscellaneous orders that I’ve missed. I’ll also check in with them and make sure they are okay personally, as losing a patient is never easy.
When it comes time to pronounce your patient, be respectful of the family in the room. I always mention that I am so sorry for their loss, but I have to do one final exam. I’ll then explain that I need to listen to the heart and lungs, and shine a flashlight into the eyes to check the pupils. I’ll always allow a family to stay if they wish. After the death exam is done, I will again state how sorry I am, and leave the family with their loved one. Another thing I do is call the patient’s primary care physician and let them know about what happened to their patient.
Death is never easy. We in the ICU face death often, and we have all seen prolonged suffering in many patients with horrific disease. It is my hope that, by using the skills in this article and the prior one, you will be comfortable having difficult discussions with patients and families, and will now know how to treat suffering at the end of life in patients whose goal is to be comfortable.
- Review your institution’s comfort measures orderset and be familiar with what medications are available.
- Be respectful of the family and what traditions, prayers, or religious ceremony they may wish to enact at the end of life. Death rituals are immensely important in many cultures and should be respected.
- Please do not fear overdosing your patients with opiates – you are ethically obligated to treat your patient’s discomfort if their goal is to be comfortable, and there is no good evidence that suggests opiate administration at the end of life hastens death.
- COMMUNICATE! Be in constant contact with the patient’s nurse and RT. Promptly respond to all needs.
- Check up on your team and make sure they are okay; losing a patient is not an easy process and is emotionally taxing.
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