Medications Are Administered Freely

In fact, in dying patients, small amounts of morphine are effective for treating distress associated with breathlessness. Medications are administered freely, if needed, to individuals who are drowsy, and they aren’t given if brain death has occurred. An overdose of morphine will stop breathing and hasten death, but in terminal care, the dosage is carefully monitored and increased over time. Used in this way, the drug doesn’t slow or stop breathing. Often, we start a morphine infusion to resolve grimacing or labored breathing and gradually increase the dosage. A benzodiazepine drug can be increased slowly until symptoms of agitation or restlessness are controlled. In deeply comatose individuals, this might not be necessary unless breathing after extubation becomes markedly labored. In our institution, it’s common practice to start a morphine infusion and increase the dosage in small increments every 15 minutes until a patient is free of pain. We may also do the same thing with the sedative drug lorazepam, adjusting it until we’re able to control an individual’s agitation or restlessness. None of this is indicated for deeply comatose patients unless their breathing becomes markedly labored after being removed from a respirator. We always let families know that the starting doses may not be enough to prevent suffering, particularly in a person who has partially recovered from a coma. None of these drugs instantly alleviates distress.

One Of Those Days

Relief sometimes doesn’t occur until analgesics and sedatives reach their peak effects. The clinical signs of respiratory distress are restlessness, moaning, agitation and changes in vital signs. Even when they’re present, however, we can’t be sure that a person is suffering. Conversely, even when patients are unable to express discomfort, they may still be aware of it. This is why we have a strategy for providing compassionate care in patients no longer on a respirator who’ve recovered some awareness. The sedative medication midazolam is the drug of choice for compassionate extubation. Another medication that may be used is the anesthetic propofol. Much has been written about the adverse effects of propofol, including deep sedation and impairment of breathing, but those concerns are misplaced when an individual is likely to die within a couple of hours. Therefore, experienced palliative care physicians will likely start with midazolam and add fentanyl to ease any pain. This drug combination results in quiet sedation. The deepest emotional responses of family members tend to occur when the tube is removed, making way for acceptance. We position the patient to facilitate airflow, and care providers may frequently need to suction mucus from the airway.

The Take Off and Landing of Everything

Administering supplemental oxygen isn’t beneficial and doesn’t relieve symptoms. Glycopyrrolate reduces saliva and drooling. Scopolamine relaxes the smooth muscles, and both drugs dry up secretions from the exocrine glands. Dry mouth is managed with oral hygiene every 2 to 4 hours, smoothing the lips with petroleum jelly, and moistening the air. A number of other steps are taken in advance to prepare for things that can happen to the body when a patient is dying. Hiccups can be relieved with the medication baclofen. Extreme agitation can be treated with the medication lorazepam or the medications midazolam or propofol. Medications may also be administered to prevent seizures. I tell them the names of the medications and what they do, even if the names sound daunting. Otherwise, family members may misunderstand what we’re trying to do or wonder if our actions are in their loved one’s best interests. We go so far as to obtain consent from family members for use of the drugs so there are no misunderstandings. There are other important considerations when care is withdrawn.

Life Itself

All unnecessary equipment in their rooms should be disconnected and displays removed, although monitoring continues remotely. Noise and light in their rooms should be minimized. Chairs and tissues should be available for family members. Physicians may be present, but they’re often silent and respectful. Historically, in our institution, the only visible indicator that the individual was dying was a closed curtain. When people see the pictures, they often pause, become silent and reflect. Candles have immense religious symbolism, but they also evoke peace, quiet and tranquility in the absence of any faith or belief system. They’re neutral, universal symbols. We’ve found that posting these signs significantly reduces the noise level, particularly from staff conversations. We don’t pretend that these pictures alleviate the bereavement process, but the response to this simple gesture has been overwhelmingly positive. These placards are only used when individuals have transitioned to comfort care, their families have come to full agreement about withdrawal of support, and doctors anticipate a brief dying process. We provide other measures, such as dimming of lights to create a calm atmosphere. We encourage families to bring to the bedside favorite items, such as photos, religious articles or quilts. We allow soft music and may prop a patient’s head up with a favorite pillow or wrap the patient in a favorite blanket or quilt, if there is one. These rooms offer a quiet place for family members to sit, gather their thoughts, reflect, and let go of their emotions. Reflection rooms are usually peaceful and quiet, similar to a chapel. Reflection rooms can also be a place where chaplains visit with family members. If there’s a possibility that a death was not due to natural causes, the individual’s personal belongings are considered evidence and placed in paper bags. If next of kin aren’t present and the patient had no advance directive, permission will be obtained through a recorded phone call. An autopsy then will be performed within three months. The hospital is required to send an autopsy report to family members. The cause of death and what led to it are rarely a surprise, but the information may provide an opportunity for family members to discuss with physicians any uncertainties about what the final, definitive diagnosis means. Some people go through these stages, but for many others, grief may endure until a veil lifts. When that will happen can’t be predicted. When is organ donation even considered?