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Department: Critical Issues

End-of-life care in the ICU

The ethics of sedation

Rong, Jessica MSN, RN, CCRN-K

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doi: 10.1097/01.CCN.0000694104.93935.d6
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End-of-life care is an important part of modern ICU care. Landmark court decisions have gradually reshaped clinicians' views of ICU care goals at end of life from a more paternalistic mentality at the conception of ICUs in the 1950s to the more family- and patient-centered approach seen today.1 Collaboration and a shared decision-making model is now the norm.1 When further life-sustaining treatment is determined futile or is no longer achieving the patient and family's goals of care, the family may choose to withdraw that therapy. Once that decision is made, the focus shifts to comfort care.

Much variation currently exists in the delivery of end-of-life care in the ICU. There is no concise policy for how end-of-life care in the ICU should be performed. Clinicians also hold a variety of opinions on how best to manage distressing symptoms during the dying process. The priority in treatment should remain symptom management, and critical care nurses should administer medications as the patient needs them.

Compassion through dignity

The provision of compassionate end-of-life care in the ICU falls primarily on critical care nurses. Efstathiou and Ives state that compassion through dignity can be provided by the following: symptom control, physical cleanliness, removal of technical apparatus, and emotional support to family members.2 When the decision has been made to discontinue life-sustaining treatment, providers should look at all treatments and determine if they are providing a comfort to the patient; any treatments that do not provide comfort should be discontinued.2 This typically involves the discontinuation of antibiotics, dialysis, vasopressors, and mechanical ventilation. Prior to extubation, patients are adequately sedated and are then removed from mechanical ventilation.

Use of sedation at end of life

A main priority in end-of-life care is patient comfort. To achieve comfort, larger doses of medications may need to be administered. The concept of palliative care is supported by US law. A 1997 U.S. Supreme Court decision by former Chief Justice Rehnquist states, “It is widely recognized that the provision of pain medication is ethically and professionally acceptable even when the treatment may hasten the patient's death if the medication is intended to alleviate pain and severe discomfort, not to cause death.”3

The use of anesthetics, such as propofol, at end of life may be considered in the case that sedative medications such as benzodiazepines in conjunction with opioids for pain management cannot control symptoms; however, anesthetic use can be considered controversial when administered to patients who are not intubated.1 The American Society of Anesthesiologists provides a clear definition of sedation with four levels, including anxiolysis or minimal sedation, conscious sedation, deep sedation, and general anesthesia.4,5 However, according to Bodnar, the definition of sedation in hospice and palliative care is “murkier.”4 He discusses that in practice, many patients at end of life may require deep sedation to a Richmond Agitation Sedation Scale (RASS) score of -4 or -5 to adequately manage symptoms.4 At a RASS of -4, the patient shows no response to verbal stimuli but may show a response to physical stimuli. At a RASS of -5, the patient will show no response to verbal or physical stimuli.6

In 2012, Billings proposed that “any potentially conscious and imminently dying patient who is undergoing withdrawal of ventilatory support and hence faces the extreme distress of respiratory failure should be offered preemptive high doses of opioids and sedatives for anesthesia, or at least deep sedation to assure comfort, regardless of concerns about depressing respiratory drive.”7 Truog, Brock, and White published a paper examining Billings' claim that patients should receive general anesthesia prior to extubation at end of life.8 The findings here suggested that the decision to use anesthesia prior to extubation should be made in conjunction with patient and family wishes.8

Doctrine of double effect

For an action to be justified by the doctrine of double effect, the following five conditions must be met:8

  • The act itself must be morally good or neutral. (Administering medication is morally neutral; it can be good or bad based on the situation.)
  • The good effect must be the intended effect. (The intended effect of the medication administration is that the patient will be symptom-free.)
  • The bad effect is merely foreseen, not the intended effect. (The effect of hastening death with larger doses of sedation or anesthesia is foreseen, but it must not be the intended effect.)
  • The bad effect cannot be the means to the good effect. (The hastening of death cannot be the means for the relief of symptoms.)
  • The good must outweigh the bad. (The risks of hastening death with administration of anesthesia versus the patient suffering at end of life should be individualized based on the values and preferences of the patient.)

Kompanje and colleagues acknowledge that palliative administration of opioids is perceived as hastening death; however, many studies have shown that it does not affect survival in patients receiving palliative care in the ICU.9 They argue that the death of patients in the ICU after withdrawal of ventilatory support is usually related to fatigue and dysfunction in multiple organs and not due to opioid administration.9 Walton and Bell also argue that the actual cause of death remains the underlying pathologic process and that if the chosen pharmacologic regimen during withdrawal of life-sustaining treatment is used for preemptive or reactive relief of discomfort and distress, it is not the cause of death.10

Conclusion

Symptom control is the priority at end of life. A variety of opinions exist on how to best manage distressing symptoms during the dying process, but the consensus is that use of medications such as opioids and benzodiazepines is acceptable during the withdrawal of life-sustaining therapies. Anesthetics, such as propofol, are more controversial but have also demonstrated a usefulness in end-of-life care and palliative sedation. The intention of the administering provider is important, as they must adhere to the doctrine of double effect. If symptom management is the priority of the provider, the administration of medications should be permissible regardless of their potential to hasten a patient's death. Critical care nurses providing end-of-life care in the ICU must have a good understanding of common medications used at end-of-life and how they are best used to treat symptoms.

REFERENCES

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4. Bodnar J. A review of agents for palliative sedation/continuous deep sedation: pharmacology and practical applications. J Pain Palliat Care Pharmacother. 2017;31(1):16–37.
5. American Society of Anesthesiologists. Committee on Quality Management and Departmental Administration. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/anesthesia. 2019. www.asahq.org/standards-and-guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedationanalgesia.
6. Society for Critical Care Medicine. Richmond Agitation Sedation Scale. SCCM.org. https://sccm.org/LearnICU/Resources/Richmond-Agitation-Sedation-Scale-(RASS).
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10. Walton L, Bell D. The ethics of hastening death during terminal weaning. Curr Opin Crit Care. 2013;19(6):636–641.
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