Caring for Imminently Dying Patients

AJ Winer

Overview

  • Whether you are working in an ICU or the floor, you should be able to recognize the signs of a patient who is imminently dying. Signs and symptoms are broad and depend on the underlying etiology, but they frequently include changes in vital signs (bradycardia, arrhythmias, hypotension, hypoxia), decreased responsiveness, irregular breathing (rapid shallow breathing, apnea), difficulty clearing secretions, delirium.
  • For pts receiving end-of-life (EOL) care, to minimize discomfort, It Is Important to discuss with patients, families, and interdisciplinary team members which interventions can be discontinued (i.e. lab draws, blood pressure monitoring, removing central line, A-line, etc.). These interventions should be referred to as "withdrawal of support" or “withdrawal of life-sustaining therapy” (rather than withdrawal of care).
  • Certain patients (or a pt's family) may elect for compassionate extubation (see section below).

Medications for patients who are imminently dying

General recommendations:

At VUMC, there is a very helpful order set titled “Comfort Care Orders (Trauma, MICU, SICU, NEURO ICU, Palliative Care)”

Make sure to remove unnecessary medications, labs, telemetry, nursing text orders, etc.

  • Pain and dyspnea:
    • Morphine 2mg IV or SQ q1h PRN (avoid if renal failure)
    • Hydromorphone 0.25 – 0.5mg IV or SQ q1h PRN
    • Fentanyl 25-50mcg IV q15-30min PRN
      • Fentanyl is not a great option in ICU unless already on a continuous fentanyl infusion (bolus lasts only 15 mins)
      • Write as PRN, as needed for pain > 2/10 or for air hunger
      • If ineffective after 1 hour, increase by 50-100%
      • If given every hour for 3-4 hours, consider an infusion (given PRN dose as hourly rate). Alternatively, can use RDOS (see below)
  • Dyspnea/tachypnea:
    • Assess for volume overload, considering decrease or stopping IVFs or tube feeds - Opioids are the treatment of choice for dyspnea
    • Consider benzodiazepines for air hunger not controlled by opiates
    • Supplemental oxygen for comfort (do not base on O2 sat). Consider use of cool air or fan
  • Restlessness/agitation/anxiety
    • Assess for urinary retention, constipation, pain, and other modifiable factors
    • Lorazepam (Ativan) 0.5 – 1 mg PO or IV q4h PRN (tablet can be made into slurry if pt is experiencing dysphagia)
  • Secretions
    • Position for comfort; side lying if possible to move sections
    • Remember: The pt is NOT bothered by their own secretions, and it is often the family and caregivers who are likely disturbed, so avoid deep suctioning.
    • Glycopyrrolate (RobinulTM) 0.2 – 0.4 mg SQ or IV q6h PRN
    • Atropine 1% ophthalmic solution 2 drops sublingual 2-4h PRN

Compassionate Extubation and The Respiratory Distress Observation Scale (RDOS)

  • Compassionate extubation (CE) refers to the termination of mechanical ventilation and the withdrawal of an artificial airway to avoid prolonged suffering at the EOL. CE replaces the older terminology (terminal wean, terminal extubation).
  • The Respiratory Distress Observation Scale (RDOS) is a tool to help titrate medications for comfort during CE and EOL care. It uses 8 categories to create a respiratory distress score that guides med administration. While it is used mostly by nursing and RT to decrease ventilator support and sustain comfort, it is important to know RDOS components.
    • Components:
      • 1. HR per min
      • 2. RR per min
      • 3. restlessness (non-purposeful movements)
      • 4. paradoxical breathing pattern
      • 5. accessory muscle use
      • 6. grunting at end-expiration
      • 7. nasal flaring
      • 8. look of fear
      • Each of the 8 components is scored from 0-2 for increasing intensity. The scores are summed. Scores can range from 0-16, with 16 signifying the most severe distress. RDOS scores can be found under summary and flowsheet for patients undergoing CE.
  • For withdrawal of support and not on an infusion:
    • RDOS goal <2. Assess RDOS q15min, dose morphine 2mg IV q10min for RDOS ≥4.
    • If after 2 doses, RDOS 3-6 → increase bolus 50%; if RDOS >7 → increase bolus 100%
    • If ≥2 bolus doses are given over 2 consecutive hours, start an infusion
  • For withdrawal of support and on an infusion:
    • If RDOS <4, maintain current infusion. Assess RDOS q15min during wean.
    • If RDOS >4, bolus q10min
    • If ≥2 bolus doses are given per hour, increase infusion
Last updated on