Neuro ICU - Withdrawl of life support...is this so wrong?

[Nacki]

I am a traveler and had my first withdrawl of life support at this facility. Well I recieved the order to Extubate, turn off Dopamine, give 5mg Morphine IVP and to leave Diprovan on for comfort. My charge nurse and Director compared this to Euthanasia....because the Diprovan was on. I specifically asked the doctor about leaving the Diprovan on and he said he wanted him comfortable. I completly agreed. My Director and charge nurse say its wrong because if you had a healthy pt on the vent and extubated them leaving the Diprovan on they would die, I could see their point but my pt was NOT healthy and was already agonal breathing on the vent, sooooo it helped with the agonal breathing, gagging and coughing if the Diprovan was off and the ETT was pulled. What do you guys think about this?

[CrunchRN, ADN, RN]

The patient described never seemed to be in pain or discomfort so a nice twilight sleep seems perfectly fine.

If they had pain, or if they were a hospice patient then MS would be used.

As long at the patient is comfortable and their wishes were followed i just do not see the big urgency in going by the book.

I thought the nurse did a good job and truly cared for and about her patient.

[nrsang97, BSN, RN]

I have to agree with Trauma on this. Nothing was done wrong. There was plenty of room for repeat dosing. Sounds like this pt was expected to pass rather quick. If the pt was expected to be around for a few hours and even days then I would too have argued for a analgesic gtt such as MS or fentanyl. I guess I just don't see how the OP co workers called this euthenasia. What awful things for them to say.

[Tweety, BSN, RN]

Sounds like the diprovan was left on for palliative sedation.

Agree. It certainly wasn't left on to murder the patient.

[interleukin]

Hi,

Any and all appropriate Rx should be available to facilitate the best death possible. The nurse should be well aware of the particular injury and generally what will follow with extubation. But no clinician--however skilled--knows for sure, or should ever predict, what will happen.

The "double effect" of sedation and quickening death has been long discussed in the literature. Facts are; Be there and be prepared to immediately provide what is needed to mitigate air hunger/distress. Pre-medicate with glycopyrrolate iv if excessive secretions are anticipated. Excessive secretions will make for an incredibly disturbing course of death for all involved and you'll be behind the eight ball trying to fix it when the family is at bedside. You cannot always make it pretty and you cannot over bolus to make yourself or family more comfortable. That's the fine line one must be cognizant of. Know your drugs and, if anything, give a bit more rather than less. You only get one shot at a good death...and that's not the time for experimentation.

[Noryn]

My personal opinion is that you did nothing wrong however my professional opinion (and that is all it is) is that it likely could be construed as active euthanasia.

I am not sure that Diprivan is within the standard of care for a dying patient that is not ventilated. The major effect of Diprivan along with sedation is its anesthetic properties including respiratory and cns depression.

It really is a fine line. You can give morphine as long as your intent is to manage pain but at the same time, you cant give a 200 mg iv bolus and say, "I was only wanting to keep them out of pain."

Ultimately you are hitting on a subject that needs to be talked about. I think often passive euthanasia is very cruel and often "suffering" is not treated adequately.

Again I think giving Diprivan would be hard to defend in a court or with a nursing board.

[jellybeanmead]

Well, this is interesting. I must say I am neutral. When we withdraw care, the pt is put on a Morphine drip and sometimes even Versed. The drips are able to be titrated "for comfort". I can kind of see where the MD was coming from because I have seen pts up and almost jumping out of bed on 25 mcgs of Diprovan. However, Diprovan is a general anesthetic, so I am neutral. As long as the patient had a peaceful transition.

[meandragonbrett]

D/C the diprivan and start Morphine or fentanyl gtt and a versed gtt at 3-4mg is what I would have pushed for. Just my personal opinion.

[Noryn]

Interestingly enough I read an article of an almost similar situation today.

While Diprivan is not a neuro muscular blocker like Norcuron I think the situation is very similar.

http://www.dailymail.com/News/PutnamCounty/200802130275

"The physician and the patient's wife had agreed to a "do not resuscitate" and "do not intubate" order and decided to forego further treatment. But when his breathing became labored, "the patient's family became distraught" and the wife asked that everything should be done "to keep him comfortable," the ruling said. @@@@ then administered the Norcuron.

In a letter sent to the committee on April 19, Dr. @@@@@ said, "The use of Norcuron was appropriate palliative care under the unique circumstances of a patient suffering from agonal gasping whose death was clearly imminent," according to information from the board.

But during a May 13 meeting with committee members, the physician acknowledged that the use of the drug, which is normally used to cause muscle paralysis during intubation, surgery or mechanical ventilation, was an error in judgment, the ruling said.

The board of medicine determined that the physician deviated from the prevailing standards of medical and ethical care in using the drug."

[interleukin]

That situation is radically different. That doctor and nurse who gave the drug essentially killed a patient who was dying. The difference in huge.

They did not properly prepare the family and have the proper drugs at the ready.

That doc should have been fired.

[Noryn]

That situation is radically different. That doctor and nurse who gave the drug essentially killed a patient who was dying. The difference in huge.

They did not properly prepare the family and have the proper drugs at the ready.

That doc should have been fired.

The same argument can be made with Diprivan, it will cause respiratory arrest as well. What is similar to me is that each were given a drug that typically is not within the standard of care for a dying patient yet each drug is used for anesthesia purposes. I dont think either goal was to "kill" the patient rather alleviate suffering but either way these are generally poor choices as both medications will not treat pain.

The Diprivan at least does have some sedative properties. I dont know what that doctor was thinking by giving a paralytic.

[meandragonbrett]

I think the key word is that propofol CAN cause respiratory arrest but it's not 100% going to cause it running at a few mcgs. Vecuronium will ALWAYS cause resp. arrest 100% of the time.

[Noryn]

I think the key word is that propofol CAN cause respiratory arrest but it's not 100% going to cause it running at a few mcgs. Vecuronium will ALWAYS cause resp. arrest 100% of the time.

Yeah I agree that Diprivan at low doses wont necessarily cause resp depression--I have seen it used in elective cardioversion. But I may be getting senile but when I gave it years ago for the purpose of sedation on the vent, pt generally did not breathe over the ventilator and were pretty snowed. Unless I am missing something I think the same dose used to sedate for the vent was continued on the OP's patient after extubation.