Palliative SedationAn ICU Perspective

William Anderson; B.Sc. MD FRCP(C)Department of Critical CareThunder Bay Regional HSC

Conflict Disclosure Information:

Presenter: Dr. Will Anderson

I have no financial or personal relationships to disclose

“To cure sometimes, to comfort always, to hurt

the least, to harm never”

Ajai Singh, Shakuntala Singh, Mens Sana Monographs; 2006:4:1:8-9

ICU Perspectives

• Common scenarios in critically ill patients:

• Failure of aggressive therapies

• Realization of futility

• Avoidance of undesirable outcome

• Natural progression of end-stage disease

ICU Perspectives• Common scenarios in critically ill patients:

• Failure of aggressive therapies

• Eg: Septic shock with MSOF

• Realization of futility

• Eg: Massive intra-cerebral hemorrhage

• Avoidance of undesirable outcome

• Eg: Persistent Vegetative State

• Natural progression of end-stage disease

• Eg: End-Stage COPD or CHF, Malignancies

Goals

• Optimal control of suffering at the end of life.

• Pain

• Dyspnea

• Anxiety

• Psychological or Spiritual Distress

Methods

• Optimal control of suffering at the end of life.

• Pain

• Narcotics: infusions and boluses prn

• Anxiety

• Benzodiazepines, sometimes antipsychotics

• Dyspnea

• Morphine, other narcotics, ventilatory support

• Psychologic and Spiritual distress

• Family, Clergy, Nurse, Social Work, PC Nurse, Physician and control of above symptoms.

Case Scenario #1

• 71 yo woman with severe kyphoscoliosis

• Presents with Pneumonia, Septic Shock, Acute Renal Failure, Shock Liver.

• Not feasible to intubate or do CPR b/c of body habitus

• Requiring aggressive hemodynamic support and non-invasive ventilation

• Increasing vasopressor requirements

• Progressive renal failure

• Worsening ventilatory status.....

• Now what?

Case Scenario #2

• 63 yo man with severe HTN

• C/O “worst headache of my life” then collapses at home

• Brought to ER by ambulance, intubated for airway protection

• CT-Head shows Massive ICH

• Patient’s family want to talk.....

• Now what?

Case Scenario #3

• 55 yo male found unresponsive at home

• Wife heard bump, went to investigate, calls EMS, starts CPR

• Presenting rhythm VF - total 45 mins CPR before ROSC, intubated without sedation in ER

• Admitted to ICU requiring vasopressor support

• Comatose and showing myoclonus

Case Scenario #3

• Hypothermic therapy for 24 hours with deep sedation and chemical paralysis

• Antibiotics for aspiration pneumonia

• Now 72 hours post-arrest, deeply comatose, ongoing myoclonus, no sedation for 48 hours

• Now off vasopressor therapy, respiratory function improving

• What now?

Case Scenario #4

• 95 yo Catholic Priest

• Longstanding history of heart disease, recurrent CHF

• Admitted with decompensated Heart Failure.

• DNR, DNI

• Has been on non-invasive ventilation for 8 days along with aggressive medical Rx

• Not improving, getting more and more tired......

• What should we do now?

Case Scenario #5

• 86 yo man with Hx of Myelodysplastic Syndrome, on steroids for ~1 year

• Lives with wife at home, functional

• Controlled HTN, T2DM

• Remote CVA, Aorto-BiFem bypass

• Progressive pancytopenia due to BM infiltration

• Presents with Severe Anemia (Hgb 64) and chest pain

Case Scenario #5

• Patient is DNR, DNI, doesn’t want aggressive therapy

• Admitted to Palliative Care Unit

• Transfused 3 units blood

• Progressive severe dyspnea, unresponsive to SQ Morphine and Versed

• Patient is very uncomfortable, suffering quite severely

• Family wants better symptom control; asks for IV narcotics and “palliative non-invasive ventilation”

• What do you think?

Case Scenario #6

• 63 yo woman with end-stage COPD

• Increasing frequency of hospital admissions for AE-COPD despite maximal medical Rx

• Understands that she is dying of her disease

• Very afraid of dying, doesn’t want to “suffocate to death”

• Has had non-invasive ventilation many times, finds that it helps

Case Scenario #6

• Wants to die in hospice with skilled palliative care and optimal symptom control

• Wants the option of “palliative ventilation” at the end of her life

• Should this support modality be provided to patients who need it?

• What do you think?

“A physician should essentially be human. He deals with human beings with their burden of worries, sorrows and

sufferings. Scientific training helps him to provide relief to the patient's physical ailments, but a humane, compassionate approach touches and consoles the patient's aching mind and soul. No physician or medicine can prevent death, but a caring physician can make the transition from life to death less

painful. Every physician should know his limitations, keeping in mind

the great panorama of life and the universal power that shapes it all. Thus, a good physician is also a good

philosopher.”

V Balakrishnan; “The Making of a Physician”Mens Sana Monographs; 2009: 7: 1: 184-188

Thank you!