Book Text

Care of the Dying Patient

A good death includes pain management, aggressive comfort care, maintenance of dignity, a feeling of connectedness, and financial control.^[118] One of the ways this is done is through hospice care, in which an interdisciplinary team optimizes the end-of-life period by providing medical, emotional, psychological, and spiritual care to the patient and by assisting the family in coping with their impending loss. By aggressively managing comfort issues, the patient is more able to focus on spiritual and relational matters.

Clinicians should sufficiently treat pain in the terminally ill patient and not be afraid that it may cause narcotic dependency or hasten death. ^[119] ^[120] This opinion is rooted in the doctrine of double effect, which places great emphasis on the intentions of clinicians in cases in which their actions may have both good and bad effects. The classic example is administration of morphine to relieve pain in the terminally ill patient near the end of life. Although two possible effects of the morphine are recognized and foreseen—relief of pain and respiratory depression—only the good effect (relief of pain) is intended, and the clinician is not held morally culpable if respiratory depression and an earlier death should occur.^[121] The principle focuses on the intention of the clinician in seeking to provide comfort to terminally ill

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patients, even if the clinician realizes that a side effect of the medications could be respiratory depression and an earlier death. If the clinician uses a dose of morphine far in excess of that required to make the patient physically and emotionally comfortable, or if the clinician chooses an agent without pain-relieving properties (e.g., intravenous potassium), the clinician can no longer plausibly claim that the intention of the action was focused solely on relief of the patient's pain and suffering.

Objections to the doctrine of double effect include accusations that it oversimplifies the concept of intentionality and, depending on interpretation, may release physicians from responsibility for their actions. It also centers the justification of the action on the physician's intent, rather than the patient's authorization.^[122]

End-of-life care occurs in the intensive care unit and for patients receiving mechanical ventilation. Anesthesiologists should be familiar with the difficulties related to withdrawal of mechanical ventilation ( Table 89-4 ). Questions surrounding withdrawal of treatment include questions about the appropriateness of using neuromuscular blockade to minimize events such as agonal respirations that make family members uncomfortable.^[123] Because neuromuscular blockade does not provide sedation or pain relief for the patient and may even harm the achievement of these goals by impairing the clinician's ability to assess

TABLE 89-4 -- Good care of the dying patient

Needs of the Patient Needs of the Family Needs of the Clinical Team

To have fears of dying and dyspnea alleviated To be with the patient To have key aspects of end-of-life care performed and modeled by respected clinicians

To be informed of planned events To be helpful to the patient To have a multidisciplinary team committed to cooperation, communication, and teamwork

To have pain, distress, and symptoms managed To be assured of the patient's comfort To receive ongoing education about performing clinical palliative care, supporting and counseling patients and families, and respecting religious and cultural beliefs

To be treated with respect and dignity To be informed of the patient's changing condition To have administrative support for palliative care

To have family and friends present To express emotions To have the patient remain in her or his unit throughout the intensive palliative care period, unless transferring is in the best interests of the patient or family

To have cultural beliefs honored To be accepted, supported, and comforted by family members and health professionals To have opportunities for bereavement and debriefing

To have spiritual meaning To be assured that their decisions were right To be cognizant of policies and regulations about autopsy and organ donation

To find meaning in the dying of their loved one

To be fed, hydrated, and rested

To be informed of bad news in private by a presentable senior team member in a compassionate manner using plain language (e.g., saying died instead of unsuccessful resuscitation)

Adapted from Truog RD, Cist AF, Brackett SE, et al: Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 29:2332–2348, 2001.

the patient, neuromuscular blockade should never be initiated after the decision to withdraw life support has been made. Although some may argue that neuromuscular blockade eases the anguish of the families, that argument does not outweigh the potential harm to the patient. Explaining to the family the reasons to avoid neuromuscular blockade may make it more tolerable for them to be present through the dying process.

Needs of the Patient	Needs of the Family	Needs of the Clinical Team
To have fears of dying and dyspnea alleviated	To be with the patient	To have key aspects of end-of-life care performed and modeled by respected clinicians
To be informed of planned events	To be helpful to the patient	To have a multidisciplinary team committed to cooperation, communication, and teamwork
To have pain, distress, and symptoms managed	To be assured of the patient's comfort	To receive ongoing education about performing clinical palliative care, supporting and counseling patients and families, and respecting religious and cultural beliefs
To be treated with respect and dignity	To be informed of the patient's changing condition	To have administrative support for palliative care
To have family and friends present	To express emotions	To have the patient remain in her or his unit throughout the intensive palliative care period, unless transferring is in the best interests of the patient or family
To have cultural beliefs honored	To be accepted, supported, and comforted by family members and health professionals	To have opportunities for bereavement and debriefing
To have spiritual meaning	To be assured that their decisions were right	To be cognizant of policies and regulations about autopsy and organ donation
	To find meaning in the dying of their loved one
	To be fed, hydrated, and rested
	To be informed of bad news in private by a presentable senior team member in a compassionate manner using plain language (e.g., saying died instead of unsuccessful resuscitation)
Adapted from Truog RD, Cist AF, Brackett SE, et al: Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 29:2332–2348, 2001.