icu

Ensuring the Patient's Comfort

　　It is of paramount importance that the entire care team understands that the focus of the patient's care from the moment the decision is made should now be on comfort and not cure at the expense of comfort. All members of all teams involved in the patient's care should receive this information promptly to avoid corridor misunderstandings -- especially with family -- about what to expect. It is my (and others[7,8]) belief that only those interventions that advance a patient's goals be allowed; and those that do not should be prevented or removed.
Pain
　　Sadly, many patients die with pain that could have been adequately treated.[9] This may be because of the emphasis on treating diseases rather than symptoms, or because of the inherent difficulty in grading the type and severity of subjective symptoms such as pain. Pain may be very difficult to assess at the end of life, but it is probably true that a patient who is not receiving neuromuscular blockers, is not restless, tachypneic, hypertensive, or diaphoretic is unlikely to be in severe pain.
Suffering
　　Suffering is different from pain, but there is often a large overlap between these 2 states. There are no generally accepted scales with which suffering may be quantified, and caregivers use their own perspectives to address this problem. Because many of the drugs in widespread use at the end of life also have a euphoric and/or an anxiolytic effect, it is assumed that if pain has been controlled then a large degree of the associated suffering will be as well.
Nonpharmacologic Approaches to Pain and Suffering
　　It has long been accepted that dying in one's sleep presents a satisfactory way to depart life. The body naturally protects itself from unpleasant sensations at the end of life, and this is reflected in the popular saying that "pneumonia may be the friend of the old." Hypoxemia, uremia, reduced cardiac output, ketosis, and dehydration may all cause reduced conscious level; and these effects may be managed to provide a degree of "natural comfort care" in an otherwise extremely unnatural environment. However, some degree of pharmacologic management is usually necessary in the ICU setting.
Opioids
　　These drugs are the mainstay of comfort care at the end of life in the ICU. Central microreceptor stimulation provides analgesia, sedation, respiratory depression, and a degree of euphoria. It is for these reasons that they are so widely used. Morphine represents this author's first-line treatment because it is inexpensive, effective, and easy to titrate. Hydromorphone and diamorphine are equally effective. Fentanyl is a synthetic opioid in widespread perioperative use. It has fewer sedative and euphoric effects, but does not cause histamine release. This may be helpful if a patient has previously demonstrated this to be problematic with morphine.
Benzodiazepines
　　 These drugs have anxiolytic and anterograde amnesic effects, both desirable in this setting. Their action is synergistic with opioids and may address some of the suffering effects not attributed to pain. Additionally, these drugs have anticonvulsant properties and may prevent premorbid seizure activity.
Other Options
　　Propofol and barbiturates are reportedly used as end-of-life adjuncts, but I support the SCCM Ethics Committee view that there are other more suitable agents available for terminal sedation and analgesia in most cases. There is no place for neuromuscular blocking agents, because they have no effect on symptoms, and may even cause suffering if there is insufficient sedation.