Police investigating use of opiates in comfort care case

Nurses General Nursing

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This particular case involves an anesthesiologist medicating a patient through a terminal wean (extubation to comfort care), although in my experience this is usually done by a nurse.

An 8-year-old was taken off life support, his organs donated. Now, police are investigating

Basically, an 8 year old boy drown with a down time of up to 25 minutes, he did not meet brain death criteria but apparently had severe anoxic brain injury and did not have potential for a meaningful neurological recovery. Family decided on comfort care and for organ donation. Because he didn't meet brain death criteria, the patient has to be allowed to die naturally after care is withdrawn prior to organ harvesting. In my experience this usually involves extubating, usually with family present, just outside the OR where a transplant team is waiting. For the organs to be viable, the general rule is that the patient must expire within 30 minutes of the withdrawal of life support. The person medicating for comfort gave the boy 500mcg fentanyl for reported air hunger, the boy died 19 minutes after extubation.

Luckily for the anesthesiologist, the coroner's referral of the case to police appears to be based on poor knowledge, since the suit claims the fentanyl was inappropriate since the patient was "gasping for air", which is of course exactly why opiates should be given.

The story makes it sound as though the patient received a one time dose of 500mcg, although I would think that was more likely the total given, starting with smaller doses and assessing for effect.

I have been in the situation before and it is unnerving, you're well aware of what rides on the patient dying within the required time frame, and I've had patients that failed to die on time and it's hard not to get a sense that the team is disappointed. As a result you're wary of over-treating symptoms because you don't want to be accused of trying to hasten death to meet the timeline, but at the same time you don't want that wariness to result in under-medicating the patient.

The anesthesiologist was likely there if the donor was going to be a lung donor. In DCD cases, the donor needs to be reintubated in order to be able to donate lungs.

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There isn't any need to extubate a patient for DCD.

Specializes in Med Surg.
This case will not go anywhere. The cause of death was not the fentanyl, it was drowning. The outcome was goibg to be the same once TERMINATION of life support was done. Death. Even if hastening the death by giving the fentanyl, it still did not cause the kid to die. Also remember death was the end goal of the procedure.

There is no reason to give a kid 500 mcg of fentanyl.

Specializes in Critical Care.
Sounds to me like a type error. I would bet the child got 50 mcg; not 500.

Both UCLA and a representative for the Physician have publically responded to the allegations and made no correction to the dose that was given, so they seem to be conceding that 500mcg was accurate.

Specializes in Critical Care.
This case will not go anywhere. The cause of death was not the fentanyl, it was drowning. The outcome was goibg to be the same once TERMINATION of life support was done. Death. Even if hastening the death by giving the fentanyl, it still did not cause the kid to die. Also remember death was the end goal of the procedure.

The "end goal" of comfort care is comfort, not death, death is passively allowed to occur. And yes, 500 mcg of fentanyl in a 50lb boy can certainly cause them to die. That doesn't mean it's not acceptable to hasten death, but it has to be the result of comfort measures, not to kill them.

Specializes in Critical Care.
The anesthesiologist was likely there if the donor was going to be a lung donor. In DCD cases, the donor needs to be reintubated in order to be able to donate lungs.

Also, the OPO, in this case, OneLegacy, and any other OPO in the country, has no role in the care of live patients. All comfort cares are administered per the hospital's policy and standing end of life procedures.

If the anesthesiologist was there to assist with organ donation then it's even less appropriate for them to be administering comfort care meds.

Specializes in Critical Care.
There isn't any need to extubate a patient for DCD.

Unless the patient just happens to expire before they get extubated during comfort care then they usually do need to be extubated prior to DCD since the normal comfort care process has to occur.

Specializes in Critical Care.
There isn't any need to extubate a patient for DCD.

Ummm, they are always extubated. It's actually a key part of the process...

I think that there is more to this than anybody knows. There are basically no limits in a terminal wean, and there shouldn't be. Parents should not have to watch a kid in air hunger. That's just awful.

The family was already dealing with the tragedy of their child drowning. They shouldn't have had to watch the child suffer in the death process.

So what if the fentanyl hastened death? I did a terminal wean recently and every time I gave my comfort care meds, respiration and sats dropped. You could say I hastened the death. I know I didn't. This person was suffering in their death and it was painful for the family.

It was a terminal wean. A terminal wean. Death was from the drowning and the child was being kept alive by artificial means. The death had nothing to do with the fentanyl.

Specializes in OR, Nursing Professional Development.
The anesthesiologist was likely there if the donor was going to be a lung donor. In DCD cases, the donor needs to be reintubated in order to be able to donate lungs.

Which is why it's a potential ethical issue for tanypne involved in the organ procurement to be involved in pronouncement.

Not only does my facility require a physician outside of the surgical team

be responsible for pronouncement, we also bring the ICU nurse into the OR to manage the comfort care measures to place another layer between care of the patient and organ procurement.

Specializes in SICU, trauma, neuro.
There isn't any need to extubate a patient for DCD.

They always do, to my knowledge. The pt is taken to the OR and extubated. Until the cardiac death, the pt is managed by hospital staff. (hence why the anesthesiologist is managing the meds. I'm not an OR nurse, but again to my knowledge the MDA/CRNA does the med administration in the OR.)

Once cardiac death occurs, the transplant team begins the procurement. If the pt does not die within the timeframe, (I want to say 60 minutes? does that vary by state?) he is then transferred to the floor and managed as any other comfort care pt -- not a preop donor. (I believe they still would be eligible for corneas and tissues... we notify the OPO and eye bank after every death to screen for eligibility.)

(Another side note, the OPO RN is on the unit once tge DCD decision is made. They are involved in the testing organs for viability, lung management e.g. recruitment maneuvers, making recs for fluid/lyte balance e.g. vaso for DI..... The big difference between the preop DCD and the brain dead is, while the pt is still alive, the medical orders come from the ICU MD. For the brain dead folks, the OPO RN enters all orders based on their protocols. For the DCDs, the hospital staff is quite involved.)

If the anesthesiologist intended to give a 500 mcg bolus, I agree that's wrong and doesn't do any good for gift of life PR.

One thing I wondered though, if was it intentional? Was the provider flustered by the sight of a child gasping for air, and drew up a 10x dose, like Kim Hiatt with calcium?

A few months ago I had a terminal wean (not a DCD -- standard comfort care.) Prior to extubation, based on her clinical picture I had expected her to pass smoothly and quickly. I had given her a prn dose of morphine, had a syringe of Ativan at the ready, and the RRT extubated her. Well... from the moment that tube was out, she really struggled. Vocalized with each breath, turned blue, RR around 40, arched her back in effort, struggled. I pushed several more doses of morphine without effect -- until she died. It felt like I was actively euthanizing her, except I wasn't.

Of course I didn't give her 20 mg as a single dose. Again, I don't agree with 500 mcg for an 8 yr old

Specializes in Critical Care.
I think that there is more to this than anybody knows. There are basically no limits in a terminal wean, and there shouldn't be. Parents should not have to watch a kid in air hunger. That's just awful.

The family was already dealing with the tragedy of their child drowning. They shouldn't have had to watch the child suffer in the death process.

So what if the fentanyl hastened death? I did a terminal wean recently and every time I gave my comfort care meds, respiration and sats dropped. You could say I hastened the death. I know I didn't. This person was suffering in their death and it was painful for the family.

It was a terminal wean. A terminal wean. Death was from the drowning and the child was being kept alive by artificial means. The death had nothing to do with the fentanyl.

I don't think there's any argument that there are no limits on the amount of opiate that might be legitimately required to treat distress after a terminal extubation, the question is whether or not 500mcg fentanyl, or 50mg morphine, is an appropriate first dose in a 50 lb patient.

I've given 50mg morphine during a terminal wean and extubation, but that's because I had already established 40 or 45 mg wasn't sufficient. I think there's a reasonable debate to be had about whether we should just give a massive opiate dose right off the bat, but at least currently it's not accepted practice.

The purpose of opiates when treating distress in a patient dying of respiratory failure is to artificially manipulate their respiratory drive, which by definition hastens death. There's nothing wrong with that because the primary purpose is alleviate distress, but the same effects of opiates that kill a few thousand people a year also affects comfort care patients. In respiratory failure the body correctly responds by stimulating an aggressive respiratory drive, which is distressing, so we trick the body into thinking it doesn't have to work as hard to breath as it actually does.

I don't think there's any argument that there are no limits on the amount of opiate that might be legitimately required to treat distress after a terminal extubation, the question is whether or not 500mcg fentanyl, or 50mg morphine, is an appropriate first dose in a 50 lb patient.

I've given 50mg morphine during a terminal wean and extubation, but that's because I had already established 40 or 45 mg wasn't sufficient. I think there's a reasonable debate to be had about whether we should just give a massive opiate dose right off the bat, but at least currently it's not accepted practice.

The purpose of opiates when treating distress in a patient dying of respiratory failure is to artificially manipulate their respiratory drive, which by definition hastens death. There's nothing wrong with that because the primary purpose is alleviate distress, but the same effects of opiates that kill a few thousand people a year also affects comfort care patients. In respiratory failure the body correctly responds by stimulating an aggressive respiratory drive, which is distressing, so we trick the body into thinking it doesn't have to work as hard to breath as it actually does.

They were probably already declared dead. Brain death and cardiac death are two different things. If the organ team was involved, that child was probably declared dead a long time before extubation. The child was being kept alive while the organ procurement team was getting all their ducks in a row, which can take days. But in those instances, death is declared after a brain flow study has shown no activity. With an anoxic injury, that often happens.

That's why I'm saying there is more to this and the coroner screwed up by not understanding the process. We all need to not place judgement unless we were there and know the details of the case.

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