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

Specialties Neuro

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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?

What do you all think of 1mg Dilaudid q10 min. after extubation on a withdrawl pt????I am a newer nurse and am still very uncomfortable with the whole "withdrawl" process. I feel that ultimately, yes, I should make my pt. comfortable but I, as do all the nurse who push multiple doses of Dilaudid and Morphine know that they can cause severe resp depression and ultimately death. I don't know?? I don't look forward to the day I have to do this. To the OP at out facility we do not leave on Diprivan gtts, we give multiple doses of Dilaudid, Morphine, Robinol etc. Also just wanted to add, Morphine q30 min??? From what I have seen that is a crazy long time! Our orders during extubation never have more than a 5-15 min. time frame. I don't know if this is "right" or not? Like I said I am still in orientation, haven't actually pushed end of life drugs myself.

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Specializes in Author/Business Coach.

Thank you for bringing that up. Morphine and other narcotic pain meds can cause resp depression speeding up death. I think other posters were upset because Diprovan does not help with pain. My pt never appeared to be in pain, he was completly unresponsive w/o the Diprovan,but was actively agonal breathing with the vent. That's why the Dr. wanted to leave the Diprovan on. I know 5mg Q 30mins doesn't sound like alot...its actually 10mg every hr. If I had gotten a Morphine gtt the dose he would have provided would be only 3mg/hr...so it was more than the norm for this specific facility.

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I haven't read much of this thread, but I have taken care of several patients of which we have withdrawn support on my shift. I did this just yesterday.

I find it extremely rewarding to help someone 'die with dignity' and support a family in a time of terrible grief. It's especially refreshing when a family member actually acts upon their family member's (the patient's) wishes and does withdraw.

I find it more difficult to take care of a patient that did not want to be re-intubated/full-code, etc. and the family goes ahead against his/her wishes.

I have worked with both of these types of situations.. I would rather help someone die, than keep them alive against their wishes.

Upon extubation, I give as much ativian/morphine as I can and as frequently as I can, as ordered.

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Specializes in Acute care, Community Med, SANE, ASC.

I'm new to neuro ICU but, in my opinion, I don't think you did anything morally wrong but I'm not familiar with the law with regard to Diprivan in this situation.

I do think that Diprivan provides comfort because it is a sedative-hypnotic and this to me indicates that it would help with relaxation, which I consider comfort. I do not think providing comfort always means pain relief as in a narcotic. In fact, to me, if the patient does not appear to be in pain I think it makes more sense to provide comfort in the form of anxiety relief and relaxation than it does to snow someone with narcotics.

My interpretation of the original post was that the patient didn't seem to be in pain, although I realize we can't know that but I think we have to treat as best we can based on our assessment. I don't think we know for sure that dying from withdrawal of care would necessarily be painful but to me it seems that it would be more anxiety and even panic producing, which I think is better controlled with meds for those conditions than meds for pain like narcotics.

Just my 2 cents

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Specializes in Author/Business Coach.

My sediments exactly. This is the point I've been trying to get through to everybody else who thinks my position on this was wrong. Thanks

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Specializes in Acute care, Community Med, SANE, ASC.

NurseCutie,

You're welcome. I wasn't sure I was getting my point across but it sounds like maybe I did.

I formerly worked on a spinal surgery floor where EVERYBODY is in pain. One of my biggest surprises in neuro ICU is how many of the patients deny pain. I realize they have brain issues so maybe they aren't able to express themselves but pain seems to be a relatively rare issue in neuro ICU compared to where I came from where I jokingly described myself as a licensed drug dealer.

I guess my thought is that if I were A&O and having care withdrawn from myself I wouldn't want to be snowed on narcotics but rather I would like anti-anxiety meds so that I'm alert (if possible) but not panic-stricken.

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Specializes in critical care.

I was not involved in this but, heard about it when I came in on Sunday. This patient was having life support withdrawn, and the CCP pushed 300mg of fentanyl, after extubation...he of course died within minutes. Now that could be considered euthenasia. (none of the nurses would push that amount, hence the doc did.)

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I think you are a kind and compassionate person and I would want you to take care of me when my times comes.

Keep them comfortable even if it does mean hastening their death (and I'm not saying this did).

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Specializes in critical care.
I think you are a kind and compassionate person and I would want you to take care of me when my times comes.

Keep them comfortable even if it does mean hastening their death (and I'm not saying this did).

FYI OP, I think you did right too. Not a prob here. Some people in nursing wouldn't see it that way.:twocents:

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Double check this but I'm pretty sure that per FDA only a CRNA or MDA can use propofol on a non-intubated patient. As I'm sure you are all aware, we as RN's can't push propofol for conscious sedation. I ran into this situation a few years back: the doc wanted propofol for conscious sedation & it was a big to-do, resulting in a CRNA being at bedside to do so. The PharmD stated that it was because RN's can only use propofol on patients who have protected airways because it is an induction agent. I'm not sure if it was just our hospital policy or if he was correct so double check.

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Specializes in Author/Business Coach.

I completly understand this. I would never give Diprovan to a non intubated pt. I can see in this instance thought that it is a very fine line about what is right or wrong. I just wanted to know what others thought of this situation. Thanks.

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The use of Diprivan is seen more and more in palliative care, especially in oncology, therefore, on non-intubated patients. It's used for conscious sedation with patients who respond poorly to benzo, or as a treatment for severe nausea and vomiting. As for who can or cannot give Diprivan to a non-intubated patient, I suggest you double-check. In my facility, we can, but its not in USA. We often have a Diprivan perf for our non-intubated patients, to be titrated according to a prescribed RASS score.

IMO, I think you did right !

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