Comfort in terminal extubation: Minimal evidence, maximal need

Studying the dying process and terminal extubation in particular, is clearly a challenge. Are the measures we choose even relevant to the person in the bed? We may never know. Nevertheless, some brave souls have attempted to offer their best effort on it. What they mostly do is retrospectively review the chart for processes of care and trends of results. This amounts to little more than consensus of expert opinion but is the best most have been able to achieve to date.

A few trends became obvious as one team reviewed this literature and offered their own local experience. Some of this is just plain common sense. For example, if you don’t need to use devices to maintain patient comfort or resting safety, then don’t. If you don’t need to start an intravenous to give medications, then don’t. Use alternate routes. We have oral morphine (Roxanol) and we can use atropine eye drops under the tongue for secretions. Never stop comfort measures already in place, such as benzodiazepines (Kompanje, 2008). Truog et al. (2008) reminded us all that the goal is to support dignity and comfort, providing quiet, comfortable spaces for the patient and family, absent the trappings of technology, full of human caring. Turn off the alarms and monitors.

Experts argue about the speed of withdrawal of the endo-tracheal tube, but are clear that there are circumstances where it is not appropriate to remove it: large volume of secretions and swollen tongue , for example (Campbell, 2007). Truog et al. (2008) cited the absence of evidence governing this subject. They further noted that rapid withdrawal may cause dyspnea and related discomfort.

Fear of causing a premature death via opioids paralyzes some. Mazer et al. (2011) found that the mean dose of morphine just before death was about 10 mg. During the last hour of life each 1 mg/hour increment of morphine infused was associated with a delay of death by 7.9 minutes. The authors encouraged practitioners to reduce their concern for premature death and act purely on the patient’s assessed needs for comfort.

Truog and colleagues (2008) did their best to summarize care recommendations in a consensus statement by the American College of Critical Care Medicine. This was published in Critical Care Medicine, in 2008. Authors included nurses and physicians knowledgeable in the field. Although many hope this will change as time goes on, around 20% of all deaths in the United States occur in ICUs. Clinicians need to apply the same vigor to dignity and comfort preservation as they do to life saving.

Kompanje, E.O., Van der Hoven, B., & Bakker, J. (2008) Anticipation of distress after discontinuation of mechanical ventilation in the ICU at end of life. Intensive Care Medicine, 34, 1593-1599.

Mazer, M. A. (2011). The infusion of opioids during terminal withdrawal of mechanical ventilation in the medical intensive care unit. Journal of Pain and Symptom Management, 42(1), 44-51.

Truog, RD et. al. (2008) Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American Academy of Critical Care Medicine. Critical Care Medicine. 36(3), 953-961.

Submitted by:
Kathy Russell-Babin, MSN, RN, ACNS-BC, NEA-BC
Sr. Manager, Institute for Evidence-Based Care
Meridian Health System

Posted: 4/16/2012 7:47:38 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

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