Post-arrest status myoclonus

[MunoRN, RN]

I've come across varying views on futile care at different places I've worked, but one issue that always causes a lot of friction between doctors and between doctors and nurses is when a post-cardiac arrest patient is in status myoclonus, particularly when the myoclonus started in the first 24 hours after arrest and when there is evidence of anoxic brain injury, since there doesn't appear to be any evidence any patient has ever recovered from this state.

We do have a few intensivists that will almost immediately declare these patients futile once they take over care, but others tend to just go along with the neurologists who are always hesitant to accept what appears to be a well defined prognosis of zero.

Where things get testy is that the neurologists often ask that we withhold all analgesia and anxiolytics for at least 24 hours before they will agree that the patient's prognosis is irrecoverable.

We've brought individual cases to our ethics committee who have overruled the request for holding analgesia and sedation and that the patient should be immediately transitioned to comfort care, but that it should be up to the nursing staff to implement a more permanent change in practice, so has anybody experienced a different routine practice for these patients or is this just as good as it's going to get.

[Kitiger, RN]

This is new to me, but - if I understand this article correctly - it is possible to recover from post-arrest status myoclonus. This article was published in 1998, so it may not be reliable. I'm interested it what others have to say.

Early myoclonic status and outcome after cardiorespiratory arrest | Journal of Neurology, Neurosurgery & Psychiatry

[MunoRN, RN]

This is new to me, but - if I understand this article correctly - it is possible to recover from post-arrest status myoclonus. This article was published in 1998, so it may not be reliable. I'm interested it what others have to say.

Early myoclonic status and outcome after cardiorespiratory arrest | Journal of Neurology, Neurosurgery & Psychiatry

That actually refers to Lance-Adams syndrome which is a type of myoclonic disorder but is separate from anoxic status myoclonus, Lance-Adams is well known to have a potential for recovery. Patients with Lance Adams don't have significant anoxic brain injury on imaging or EEG (MRI is preferred), so a patient with no confirmed anoxic injury but who is having myoclonus shouldn't be assumed to have status myoclonus due to irrecoverable anoxic injury.

Status myoclonus onset within 24 hours with confirmed anoxic injury however has never resulted in survival.

[KatieMI, BSN, MSN, RN]

Totally agree.

It is written in every single textbook, every guideline that EEG, evoked potentials, fPET, fMRI, MRA, etc. are not, in any case, predictable of anything. Yet, there are some neurologists who clearly abuse system under premice of "telling them what they want to hear" and "not robbing them of hope". Yes, there were bare handful of unpredictable "recoveries" (BTW, nothing that happened before 2003 - 2005 when fMRI and fPET scans got out of purely academic settings can be relied upon and certain conditions like anoxic myoclonys and Lasarus syndrome are virtually predictable of no meaningful recovery ever possible) but even without all that overall chances for somewhat meaningful return of consciousness and personality are negligible and what happens next is, IMHO, sometimes becomes borderline torture or corpse desecration.

It is nor nursing role to tell patients all that, especially in our days of "customer servive" everything. But it can and should be RN role to alert higher-ups, risk management, social work, clergy and physicians/providers who feel comfortable speaking with families in distress and do whatever to make family hear the holy truth. And, of course, the first thing to be withdrawn must be "customer satisfaction".

IMHO again, "ethics committee" must stop being a spineless gathering which issues "opinions". Once care is declared futile by people who are supposed to be experts, the patient authomatically becomes DNR for 72 - 96 h, and if no clinical progression is noted, "no code" with set data of care withdrawal within 72 h. If family still wants of wishes, they should be welcome to do whatever, but from the "care withdrawal" point of no return no insurance, and especially Medicare/Medicaid, should be allowed to pay a red penny for anything, as well as federally sponsored institutions must not be allowed to keep the patient on their premices.

If family still wants to sue, good luck for them. At least, most $$$$$$ thus redisributed will not be spent on literally moving air to and fro a dead human body.

[MunoRN, RN]

Totally agree.

It is written in every single textbook, every guideline that EEG, evoked potentials, fPET, fMRI, MRA, etc. are not, in any case, predictable of anything. Yet, there are some neurologists who clearly abuse system under premice of "telling them what they want to hear" and "not robbing them of hope". Yes, there were bare handful of unpredictable "recoveries" (BTW, nothing that happened before 2003 - 2005 when fMRI and fPET scans got out of purely academic settings, can be relied upon) but overall chances are neglugible and what happens next is, IMHO, sometimes becomes borderline torture or corpse desecration.

It is nor nursing role to tell patients all that, especially in our days of "customer servive" everything. But it can and should be RN role to alert higher-ups, risk management, social work, clergy and physicians/providers who feel comfortable speaking with families in distress and do whatever to make family hear the holy truth. And, of course, the first thing to be withdrawn must be "customer satisfaction".

IMHO again, "ethics committee" must stop being a spineless gathering which issues "opinions". Once care is declared futile by people who are supposed to be experts, the patient authomatically becomes DNR for 72 - 96 h, and if no clinical progression is noted, "no code" with set data of care withdrawal within 72 h. If family still wants of wishes, they should be welcome to do whatever, but from the "care withdrawal" point of no return no insurance, and especially Medicare/Medicaid, should be allowed to pay a red penny for anything, as well as federally sponsored institutions must not be allowed to keep the patient on their premices.

If family still wants to sue, good luck for them. At least, most $$$$$$ thus redisributed will not be spent on literally moving air to and fro a dead human body.

The neurologists have come right out and said that they would rather wait longer than is probably necessary so that it doesn't weigh on their conscious, yet also ask that we withhold all analgesia and sedation despite the patient being in status myoclonus, which has got to be one of the more torturous and agonizing things for a patient to endure if they do have any sort of awareness at any level, which is where the disagreements come from. The nursing staff continues to give at least analgesia and just documents the order to withhold analgesia is not an acceptable order, but it would be nice to have a clearer understanding between providers.

[Kitiger, RN]

That actually refers to Lance-Adams syndrome which is a type of myoclonic disorder but is separate from anoxic status myoclonus, Lance-Adams is well known to have a potential for recovery. Patients with Lance Adams don't have significant anoxic brain injury on imaging or EEG (MRI is preferred), so a patient with no confirmed anoxic injury but who is having myoclonus shouldn't be assumed to have status myoclonus due to irrecoverable anoxic injury.

Status myoclonus onset within 24 hours with confirmed anoxic injury however has never resulted in survival.

Thank you. I didn't understand.