Neuromuscular blockers--a means of palliation?

Delivery room deaths of extremely preterm babies: an observational study

OBJECTIVE

Many extremely preterm neonates die in the delivery room (DR) after decisions to withhold or withdraw life-sustaining treatments or after failed resuscitation. Specific palliative care is then recommended but sparse data exist about the actual management of these dying babies. The objective of this study was to describe the clinical course and management of neonates born between 22 and 26 weeks of gestation who died in the DR in France.

DESIGN, SETTING, PATIENTS

Prospective study including neonates, who were liveborn between 22⁺⁰ and 26⁺⁶ weeks of gestation and died in the DR in 2011, among infants included in the EPIPAGE-2 study at the 18 centres participating in this substudy of extremely preterm neonates. Data were collected by a questionnaire completed by the professional caring for each baby.

RESULTS

The study included 73 children, with a median (IQR) gestational age of 24 (23-24) weeks. Median (IQR) duration of life was 53 (20-82) min. All but one were both wrapped and warmed. Pain was assessed for 72%, although without using any scale. Gasping was described for 66%. Comfort medications were administered to 35 children (50%), significantly more frequently to babies with gasping (p=0.001). Mother-child contact was reported for 78%, and psychological support offered to parents of 92%.

CONCLUSIONS

Non-pharmacological comfort care and parental support were routinely given. Comfort medication was given much more frequently than previously reported in other DRs. These data should encourage work on the indications for comfort medication and the interpretation of gasping.

Euthanasia and the Administration of Neuromuscular Blockers without Ventilation: Should Physicians Fear Prosecution?

A common dilemma among physicians who treat the dying is whether pharmacological paralysis should be reversed prior to removal of mechanical ventilation. But what if a physician were to administer a neuromuscular blocker without ever ventilating the patient in the first place? While there is evidence that euthanasia does occur in the United States, few physicians have been prosecuted. Could these infrequent prosecutions reflect a conscious desire by prosecutors not to pursue such matters? In an effort to explore this question, chief prosecutors in four U.S. states were presented with a vignette based on an actual event involving the administration of Succinylcholine to a dying patient. Response rates in this study were very acceptable (76.36% overall), and results indicated that not only was the likelihood of criminal prosecution low, almost half of the prosecutors believed that a physicianadministered lethal injection may be morally justified in some circumstances even though illegal.

Dutch pediatricians' views on the use of neuromuscular blockers for dying neonates: a qualitative study

OBJECTIVE

To assess Dutch pediatricians' views on neuromuscular blockers for dying neonates.

STUDY DESIGN

Qualitative study involving in-depth interviews with 10 Dutch pediatricians working with severely ill neonates. Data were analyzed using appropriate qualitative research techniques.

RESULT

Participants explained their view on neuromuscular blockers for neonates with a protracted dying process. Major themes were the interpretation of gasping, the role of (the suffering of) the parents, the need for judicial review and legislation's impact on the care participants provide for dying neonates.

CONCLUSION

The interviews show no consensus between pediatricians and provide insights into the points of disagreement. Interviews also suggest friction between the convictions of pediatricians and legislation, which seems to have an undesirable impact on Dutch care for dying neonates and their parents. This study raises important questions for pediatricians worldwide to reflect upon, such as: 'what constitutes 'dying well'?' and 'what role should the parents' perspective play?'.

Ethical reflections on end-of-life signs and symptoms in the intensive care setting: a place for neuromuscular blockers?

The death of a loved one is often an ordeal and a tragedy for those who witness it, as death is not merely the end of a life, but also the end of an existence, the loss of a unique individual who is special and irreplaceable. In some situations, end-of-life signs, such as agonal gasps, can be an almost unbearable "sight" because the physical manifestations are hard to watch and can lead to subjective interpretation and irrational fears. Ethical unease arises as the dying patient falls prey to death throes and to the manifestations of ebbing life and the physician can only stand by and watch. From this point on, medicine can put an end to suffering by the use of neuromuscular blockade, but in so doing life ceases at the same time. It is difficult, however, not to respond to the distress of loved ones and caregivers. The ethical problem then becomes the shift from the original ethical concern, i.e. the dying patient, to the patient's loved ones. Is such a rupture due to a difference in nature or a difference in degree, given that the dying patient remains a person and not a thing as long as the body continues to lead its own life, expressed through movement and sound? Because there cannot be any simple and unequivocal answer to this question, the SRLF Ethics Commission is offering ethical reflections on end-of-life signs and symptoms in the intensive care setting, and on the use of neuromuscular blockade in this context, with presentations on the subject by two philosophers and members of the SRLF Ethics Commission, Ms Lise Haddad and Prof Dominique Folscheid. The SRLF Ethics Commission hopes to provide food for thought for everyone on this topic, which undoubtedly calls for further contributions, the aim being not to provide ready-made solutions or policy, but rather to allow everyone to ponder this question in all conscience.

Ethical reflections on end-of-life signs and symptoms in the intensive care setting: a place for neuromuscular blockers?

The death of a loved one is often an ordeal and a tragedy for those who witness it, as death is not merely the end of a life, but also the end of an existence, the loss of a unique individual who is special and irreplaceable. In some situations, end-of-life signs, such as agonal gasps, can be an almost unbearable “sight” because the physical manifestations are hard to watch and can lead to subjective interpretation and irrational fears. Ethical unease arises as the dying patient falls prey to death throes and to the manifestations of ebbing life and the physician can only stand by and watch. From this point on, medicine can put an end to suffering by the use of neuromuscular blockade, but in so doing life ceases at the same time. It is difficult, however, not to respond to the distress of loved ones and caregivers. The ethical problem then becomes the shift from the original ethical concern, i.e. the dying patient, to the patient’s loved ones. Is such a rupture due to a difference in nature or a difference in degree, given that the dying patient remains a person and not a thing as long as the body continues to lead its own life, expressed through movement and sound? Because there cannot be any simple and unequivocal answer to this question, the SRLF Ethics Commission is offering ethical reflections on end-of-life signs and symptoms in the intensive care setting, and on the use of neuromuscular blockade in this context, with presentations on the subject by two philosophers and members of the SRLF Ethics Commission, Ms Lise Haddad and Prof Dominique Folscheid. The SRLF Ethics Commission hopes to provide food for thought for everyone on this topic, which undoubtedly calls for further contributions, the aim being not to provide ready-made solutions or policy, but rather to allow everyone to ponder this question in all conscience.

[Problems for assessing the newborns' pain in palliative care]

Several pain scales are available for newborns, but the assessment of pain in these preverbal beings, who are in continuing neurological development, remains challenging for healthcare teams. Although neonates at the end of life are particularly vulnerable to pain and discomfort, no assessment tool has been validated in this specific population. The difficulties for assessing pain in this context are copies of those potentially encountered in other situations. Questions arise about the limits of the available scales, about possible alterations of responses to a noxious stimulus in particular contexts (extreme immaturity, brain lesions), about possibly painful situations in palliative care, about the nature of scales to choose. Data show a perception of pain at a cortical level by extremely immature infants and the ability for neonates with significant neurological injury to express pain behaviours. For some potentially painful situations (dyspnoea, gasps, hunger) neonatal data are virtually nonexistent. Fundamental scientific data and clinical data from adults and children can give some answers. One will choose scales for which the staff is trained, easily usable (preference for behavioural scales), validated for all gestational ages, reliable in the event of neurological impairment or sedation. An assessment of prolonged pain (EDIN scale or COMFORT Behaviour scale) combined with measures of acute pain (DAN or NFCS scales) is recommended. These scales should be better validated for populations of newborns and situations that are specific to palliative care. A better assessment of the parental perception and of their distress about the discomfort or pain of their child is warranted.

End of life decisions in chronic lung disease

Staff may be reluctant to discuss end of life decisions in chronic lung disease (CLD) as it is usual for the disease to take a prolonged course and most infants recover to be discharged home without supplemental oxygen. A minority suffer a protracted and very severe illness in spite of treatments. Further intensive care may prolong a distressing death rather than offer any hope of survival. An end of life decision may be made after discussions with parents. Assisted ventilation may be withdrawn, or care redirected to withhold further episodes of assisted ventilation. A lingering death is a risk in infants who have not yet reached the point of dying but whose care has been redirected. Tachypnoea, rib retractions and agitation are distressing for the infant and parents. Palliative care must meet the needs of parents as well as their baby. It includes the legal use of drugs to relieve the infant's distress.

Withholding and withdrawing life-sustaining treatment in children

Modern medicine gives us the ability to prolong life even in situations where it may not be right to do so. This article discusses some of the complex ethical and legal issues surrounding withholding and withdrawing life-sustaining treatment in children, including the concepts of futility, best interests and intolerability. We advocate the use of a structured framework to help guide decision-making, particularly in the more difficult situations. The lack of a morally or legally significant difference between withholding and withdrawing treatment is discussed, as is the role of the doctrine of double effect (particularly in relation to the use of neuromuscular blocking agents during withdrawal of ventilatory support).

Internists' attitudes towards terminal sedation in end of life care

OBJECTIVE

To describe the frequency of support for terminal sedation among internists, determine whether support for terminal sedation is accompanied by support for physician assisted suicide (PAS), and explore characteristics of internists who support terminal sedation but not assisted suicide.

DESIGN

A statewide, anonymous postal survey.

SETTING

Connecticut, USA.

PARTICIPANTS

677 Connecticut members of the American College of Physicians.

MEASUREMENTS

Attitudes toward terminal sedation and assisted suicide; experience providing primary care to terminally ill patients; demographic and religious characteristics.

RESULTS

78% of respondents believed that if a terminally ill patient has intractable pain despite aggressive analgesia, it is ethically appropriate to provide terminal sedation (diminish consciousness to halt the experience of pain). Of those who favoured terminal sedation, 38% also agreed that PAS is ethically appropriate in some circumstances. Along a three point spectrum of aggressiveness in end of life care, the plurality of respondents (47%) were in the middle, agreeing with terminal sedation but not with PAS. Compared with respondents who were less aggressive or more aggressive, physicians in this middle group were more likely to report having more experience providing primary care to terminally ill patients (p = 0.02) and attending religious services more frequently (p<0.001).

CONCLUSIONS

Support for terminal sedation was widespread in this population of physicians, and most who agreed with terminal sedation did not support PAS. Most internists who support aggressive palliation appear likely to draw an ethical line between terminal sedation and assisted suicide.