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

[Nacki, MSN, NP]

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?

[suanna]

Diprovan isn't a paralytic so I see no reason it should be turned off. It also has little respiratory depression compaired to benzos ar narcotics. I've weaned healthy patients from the vent with diprovan an 20-30cc/hr. We usualy d/c it at least 15 min before extubation st the patient has a better ability to clear his airway/ cooperate with extubation. Since long term recovery wasn't your goal I see no reason not to leave to diprovan on. Please be aware next time, diprovan has no pain relieving properties. 5mg of MS04 seems to be a pretty light dose.

[cardiacRN2006, ADN, RN]

Propofol has nothing to do with comfort. How sad.

5mg of morphine is nothing. I would have fought with the Dr (and won) to get something with actual comfort properties for my pt. If they were uncomfortable with a Morphine gtt, then at the VERY minimun I'd get a fentanyl patch.

If this was an extubate to withdraw care, then it was inappropriate IMO.

I've extubated to high doses of morphine gtt and fentanyl gtts. But in my facility, (and you might want to check your P&Ps), you can't give propofol to non-intubated pts, regardless of their code status. You might also want to check your state board.

[Nacki, MSN, NP]

I'm aware Diprovan has no pain relieving properties. I just didn't think the man needed to "wake up" and gasp for air if the Diprovan was taken off. Morphine 5mg was given and I had an order to give 5mg Q 30mins if needed. I didn't though because my patient died within 10mins. I agree that 5mg of Morphine is not much, but what else could I have done? I'm not the doctor and can't order more.

[Nacki, MSN, NP]

I really don't think you guys are understanding where I'm coming from with the comfort thing with Diprovan. I have been a nurse nearly 7 yrs...I know Diprovan does nothing for pain, alright? Did my original post even mention the word pain?

I can see where the Doc was coming from by allowing me to leave the Diprovan on. If I hadn't he would extremly uncomfortable when that tube came out and he was breathing on his own. Why do you think we give sedation to vented pts in the first place? If they're awake there bucking the vent and are completly aware they are breathing through a straw. How would you think a person feels when they have the labored agonal breathing AND have your ETT pulled? Its probaly realllly uncomfortable using all those accessory muscles and having no help from the vent. So if the sedation is left on to relax him I believe it helped, along with the Morphine (even though it prob was a low dose in this situation)

[Noryn]

I tend to agree with your charge nurse and supervisor. Mainly due to the approved usage of Diprivan--generally either induction or maintenance of anesthesia along with sedation of an intubated patient.

[Nacki, MSN, NP]

Ok. I can see your point on that one. Thanks.

[traumaRUs, MSN, APRN]

I think you did the right thing and no, I don't think it was euthanasia. How horrid of your co-eworkers to even suggest that! Yes, diprivan in this situation was certainly okay. Yes, 5mg of MS isn't much but as long as you could repeat it, no problem.

As to a fentanyl patch - in this situation wouldn't be appropriate because it takes too long to bring pain relief. IV MSO4 would be more appropriate with the possibility to increase and repeat the dose.

[Valerie Salva, BSN, RN]

Sounds like the diprovan was left on for palliative sedation.

[cardiacRN2006, ADN, RN]

Did my original post even mention the word pain?

No, your OP mentioned comfort, and I said that Proprfol has no comfort properties. I agree that it's horrid to not have anything for this guy.

What I said is tell the Dr that you want a morphine gtt instead of propofol. This is where you advocate for your pt.

Why do you think we give sedation to vented pts in the first place? If they're awake there bucking the vent and are completly aware they are breathing through a straw. How would you think a person feels when they have the labored agonal breathing AND have your ETT pulled? Its probaly realllly uncomfortable using all those accessory muscles and having no help from the vent. So if the sedation is left on to relax him I believe it helped, along with the Morphine (even though it prob was a low dose in this situation)

I have waitied to extubate long enough for pharmacy to bring the morphine over. FWIW, at my hospital, we never have pts just on propofol for sedation anyway. I am aware of why sedation is needed for comfort and why it's needed for intubated pts, and I am saying that propofol doens't do anything for that. You're pt wasn't comfrotable, he just didn't 'look' uncomfortable.

[CrunchRN, ADN, RN]

I think you did the right and moral thing, and I would hope to have someone exactly like you as my nurse.

[cardiacRN2006, ADN, RN]

You'd rather have propofol than morphine for comfort? Do you know anything about these drugs?

I guess I"m at a loss here.