SAN FRANCISCO—How effectively physicians manage their patients’ pain and sedation following decisions to limit life support has been intensely debated. Data from the landmark SUPPORT study show that pain management in critically ill patients is seriously inadequate.[1] Yet, other research suggests that patients in the intensive care unit (ICU) are oversedated.[2]

“More data are needed on how we manage pain,” suggested Thomas J. Prendergast, MD, at the annual meeting of the Society of Critical Care Medicine in San Francisco.[3]

“There is a need for closer attention to symptom assessment in trying to gauge the quality of dying,” said Dr. Prendergast, an Assistant Professor of Medicine and Anesthesiology at Dartmouth Medical School, Hanover, New Hampshire. “Studies have shown that there is a discrepancy between physicians’ and nurses’ and patients’ perception of how well pain is controlled,” he noted.[4] This suggests that more attention should be given to understanding the patient’s needs and desires.

PRINCIPLES OF CARE

According to Dr. Prendergast, several principles govern good end-of-life care for ICU patients. First and foremost, “Identify the patient’s needs.” He added, “Create an environment that is calmer than the typical ICU environment. When possible, arrange for the patient to have his or her own room. Minimize or eliminate distractions, including interventions or therapies not directly related to providing comfort.”

Other important principles include the following:

• Avoid unnecessary prolongation of the duration of dying.

• Help patients strengthen their relationships with loved ones by liberalizing visiting policies to allow family to be present.

• However possible, help the patient achieve a sense of control.

• Relieve burdens by being sensitive to the dynamics of the patient’s situation.

Achieving these goals can reduce the patient’s symptoms and make it easier to control pain.

ANTICIPATORY DOSING

According to Dr. Prendergast, “The specific dose of medication is less important than the principle that you titrate medications to effect and do it at the bedside in real time.” He said, “Anticipatory dosing is important, especially when withdrawing mechanical ventilation. Patients need to be medicated in advance of the procedure, and additional medications should be immediately available at the bedside.”

Dr. Prendergast also recommends liberal use of bolus benzodiazepines (both in advance of and after withdrawal of life support) and/or opioids if the patient has tachypnea or a high probability of respiratory distress. “Opioids help relieve dyspnea and slow the respiratory rate in advance of withdrawal of support,” he said.

“Bedside assessment is critical in the few minutes surrounding the actual withdrawal of support,” continued Dr. Prendergast. He advises against starting neuromuscular blockers when withdrawing life support. If a patient is already taking neuromuscular blockers, he recommends discontinuing them prior to withdrawal.

SETTING THE EXAMPLE FOR STAFF BEHAVIOR

“Physicians should model the behavior they want students, trainees, and nurses to emulate. They should set the example that it’s important to spend time at the patient’s bedside and ensure adequate symptom and pain control,” Dr. Prendergast said.

“It’s also important to spend time with the family and address the family’s needs,” said Dr. Prendergast. When the decision has been made to withdraw life support, “the family should be informed in a way that they can understand. They should be assured of the patient’s comfort,” he suggested. Showing compassion and helping families find meaning in the death of their loved one is also important.

Lastly, Dr. Prendergast emphasized the importance of addressing the needs of the clinical team both before and after decisions to withdraw life support. “It is important to establish consensus on decision making,” he said. Dr. Prendergast recommends that physicians meet with the clinical team to review the quality of the patient’s death and allow team members to express their grief.

—Deborah L. O’Connor

References
1. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598.

2. Kress JP, Pohlman AS, O’Connor MF, et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342:1471-1477.

3. Prendergast T. Pain and sedation in end-of-life care. Paper presented at: Society of Critical Care Medicine 30th International Educational and Scientific Symposium; February 10-14, 2001; San Francisco.

4. Whipple JK, Lewis KS, Quebbeman EJ, et al. Analysis of pain management in critically ill patients. Pharmacotherapy. 1995;15:592-599.

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