Police investigating use of opiates in comfort care case

[MunoRN, RN]

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 Because he didn't meet brain death criteria, the patient has to be allowed to die naturally after care is withdrawn prior to organ harvesting.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.

[offlabel]

One of the questions to be answered is whether or not the 500 mcgs were given as a bolus or not. That isn't very clear in the story. Even if that was given in divided doses, it's difficult to see where 24 mcg/kg of fentanyl would be necessary. Apnea/analgesia could reasonably be expected with 5 or 6/ kg. Giving a bolus like that because of "air hunger" (this implies he was conscious enough to experience discomfort, which he was not) with the attitude of "he's going to die anyway" is problematic to say the least.

If the parents were in attendance, there was probably some anxiety at witnessing this death so the anesthesiologist probably just wanted to intervene in the appearance of suffering in their interest. But good intentions would not excuse hastening death.

Bottom line is if she gave this kid a 10 cc bolus of fentanyl, she's in big trouble and she didn't do any favors to the organ donation cause either.

[KelRN215, BSN, RN]

I read about this story yesterday. A page I follow on facebook shared it but, my impression based on the comments of those who posted it was that none of them had any idea what a terminal wean was.

[Emergent, RN]

From what I read in the article, they crossed the line in this case. The ends do not justify the means, in my opinion. Certain boundaries should never be crossed.

The macabre possibilities are undeniable in the organ harvesting industry. We've seen it in poorer nations, with murders being committed to save wealthy recipients. It's imperative to keep things totally by the book, or we'll end up down a very slippery slope.

[Rose_Queen, BSN, MSN, RN]

I've been involved in several DCDs, some that ended up not meeting the time requirement and others that did. We always brought these patients into the OR for the wean. Family was properly attired and allowed in as well. The surgical team set up, hung drapes to hide the instruments from view, and then left the actual OR for the tiny sub sterile room beside it. The anesthesia provider was not involved in pronouncing- we bring in a resident from another specialty that does not routinely enter the OR for pronouncement.

I think that the fact that the pronouncing physician was also involved in the procurement is not a wise way to proceed. Without more info regarding the fentanyl, I'm withholding judgement on that until more details become available.

[MunoRN, RN]

I've been involved in several DCDs, some that ended up not meeting the time requirement and others that did. We always brought these patients into the OR for the wean. Family was properly attired and allowed in as well. The surgical team set up, hung drapes to hide the instruments from view, and then left the actual OR for the tiny sub sterile room beside it. The anesthesia provider was not involved in pronouncing- we bring in a resident from another specialty that does not routinely enter the OR for pronouncement.

I think that the fact that the pronouncing physician was also involved in the procurement is not a wise way to proceed. Without more info regarding the fentanyl, I'm withholding judgement on that until more details become available.

From what I can tell, the person who gave the fentanyl, an anesthesiologist, was a hospital staff MD not affiliated with the organ procurement service (One Legacy). Why this patients comfort care measures were not being managed by an RN is still not clear, the fact that a staff anesthesiologist was involved only makes it more peculiar.

If the anesthesiologist had been with the organ procurement agency that this would be more cut-and-dried, apparently there has been at least on case where a physician with an organ procurement agency became actively engaged in trying to speed up a potential donors death.

Doctor charged with hastening death of donor - SFGate

[MunoRN, RN]

The lawsuit seems to describe this as a single dose. It's not unheard of for a patient to require surprisingly large doses to treat distress after a terminal extubation, they might seem comfortable after weaning down to pressure support, but then it turns out they have little to no ability to maintain their airway after the tube comes out and the only way to achieve reasonable to comfort is to significantly reduce their respiratory drive. That's the situation we don't really like to talk about, when it appears only inducing apnea will relieve distress.

But while patients might legitimately need large doses of opiates during and/or following a terminal wean, this was the equivalent of 50mg of morphine over a very short period of time in a 50 lb boy.

[Emergent, RN]

They'd better nail this guy to the wall before this gets on social media. That's horse feathers! 500mcg is 10X a usual adult dose, at least in my experience. This was active euthanasia of someone who didn't meet criteria, so they thought they'd help him along.

This is probably the tip of the iceberg. I think this happens more than we know. This is the reason why many people are suspicious and refuse to be organ donors.

[subee, MSN, CRNA]

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

[Kyrshamarks, BSN, RN]

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.

[/username, BSN, RN]

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.

[offlabel]

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.

Then why bother terminating life support? Why not just take the kid to the OR and harvest his organs? The outcome would be the same and the "end goal" would have been achieved.