1)
The American Journal of Transplantation has an interesting article about predicting rapid death in a donation after cardiac death (DCD) setting.
Context: DCD is a technique of obtaining organs for transplantation in non-brain dead patients. In brain dead patients you can obtain presumably well-perfused, healthy organs from a patient while their heart is still beating as they are considered dead once they are determined to be brain-dead. There are some circumstances however - usually in patients with severe brain injuries but who aren't brain dead - in which life support is stopped, the patient is kept comfortable, and if they die - their heart stops beating - within a certain period of time - usually 60 minutes - they are declared dead and their organs are harvested. This is called DCD. Patients who don't quickly die continue to receive comfort-oriented terminal care. Predicting who is likely to rapidly die (which would allow them to actually donate their organs) is important because 1) families won't be given false hope that their loved one will die quickly and be able to donate their organs 2) transplant teams won't be 'needlessly' mobilized to be on stand-by to collect the organs. My sense is that palliative care teams are involved with DCD in many institutions (family decision making support prior to attempting DCD, providing symptom management to the patient after cessation of life support) - it has certainly been written about in the palliative care literature.
This paper presents a prospective, multi-institutional observational study of ~500 adults who had life support stopped with the hope of DCD - 45% of whom actually died within 1 hour. They looked at dozens of different parameters to see which ones predicted death within 1 hour. The results are complicated and I'm not going to belabor them here (in fact, depending on what sensitivity you are looking for in predicting death within 1 hour this study provides you with at least 10 different ways of doing so) - more pressors, lower Glasgow coma score, lower arterial oxygen tension, lower blood pressure, etc., etc. were all associated with rapid death. What is really interesting to me is that comfort meds - given either before cessation of life support or afterwards - were associated (in multiple analyses) with not dying rapidly. If you got morphine you lived longer.
God I love findings like that. To be fair, morphine probably didn't make people actually live longer (although it's possible - breathing rapidly and shallowly is not a good way to live a long time). Instead, in this population, healthier patients likely needed the comfort meds (had a stronger respiratory drive and so had more labored breathing, were less severely brain injured and so could show facial signs of distress, etc.) - the nearly brain dead patients breathing 8/minute did not need opioids. That said, any solid data (and this is solid data) that support the observation that many of us who care for the dying have made - that comfort meds don't usually hasten death - is good news, politically, so to speak. The next time you're doing a terminal extubation and a colleague/trainee expresses concern you're going to hasten someone's death by palliating their labored breathing - show them this article.
A thought experiment based on these findings.... Let's say we agree organ donation and DCD (when judiciously and compassionately carried out) are good things. Let's also say that there are instances in which we give opioids and comfort meds in the imminently dying not because we think the patient is suffering (experiencing pain, fear, breathlessness) but because they look like they might be. In my experience this is usually in profoundly brain injured patients who have been completely unresponsive who nevertheless have strong respiratory drives and can breath sharply and rapidly prior to dying - they look bad, to be sure, and I treat them with meds to calm their breathing just in case - but I often doubt that they are aware of anything at all. If these findings bear out under further study, particularly if it looks like comfort meds actually are prolonging life, is it ethical/appropriate to give such meds just to make someone look good if it means someone else dies for a lack of a needed organ? Please comment.
Thanks to Dr. Bob Arnold for alerting me to this paper.
DeVita, M.A., Brooks, M.M., Zawistowski, C. (2008). Donors after cardiac death: validation of identification criteria (DVIC) study for predictors of rapid death.. American Journal of Transplantation, 8, 432-441. DOI: 10.1111/j.1600-6143.2007.02087.x
2)
NEJM has a related article about the ethics of consent for organ donation (free full-text available), which discusses the potential for patients to receive otherwise unwanted invasive medical therapies (including cardiac resuscitation) if their families/docs are trying to keep them alive for DCD. Good reading.
Thursday, March 27, 2008
DCD & not hastening death with opioids
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5 comments:
I have often wondered whether an apparently completely unresponsive patient who is having rapid or labored breathing realizes any benefit from opiates. The same question comes to mind when a patient has terminal secretions and rattling is observed, who gets the benefit from levsin or atropine? The nurse? The loved ones? Probably. The patient? Doubtful. I still believe the symptoms should be treated to reduce the stress on the family and staff. Treated or untreated the patient is soon freed from his misery. The witnesses to the spectacle of a difficult death are the ones who are left to wonder whether their loved one/patient died in distress or in comfort. Hospice clinicians always have to keep in mind that the patient is part of a bigger equation which includes everyone affected by the patient.
Nolan Teter RN
I see my answer missed the last point about if someone would die for lack of a needed organ. That does complicate things. I would say that if comfort meds are prolonging a life and not actually providing any real comfort for the patient, then they should probably be withheld in favor of the organ recipient. This would seem to be an extremely difficult clinical judgment: Is the patient getting any benefit from the opiates? If yes or maybe, then the patient should get the meds. If no then, Is the administration of opiates significantly prolonging life? If no then the patient should get the meds for the reasons I stated in my first response. If yes, then, with the family's informed consent the meds should be withdrawn the same way other life prolonging interventions are withdrawn and for the same reasons. After all the "comfort meds" have at that point been determined to be just another unnecessary life prolonging measure.
Nolan Teter RN
I am not surprised that the patients who received morphine (or opioids) lived longer as it has long been clinically observed that morphine has therapeutic effects beyond analgesia. Remember one of the treatments for pulmonary edema and heart failure prior to all the fancy diuretics we use now was morphine, because it is an effective vasodilator. Often, when a patient enters hospice and is put on morphine in one way or another, and does not die as quickly as expected, the family asks if they made the right decision. We see this all the time.
JP Pinzon, DO
JP - nice to hear from you. My guess is that most readers of the blog would not be surprised with that finding, either. But how many of your colleagues do you think would be? Or residents you work with?
Nolan - thanks for the comments. The question in my mind is how do we know if a patient is suffering? How confident do we need to be that they aren't aware of discomfort or anything to allow them to die visibly taxed? What if the family was so sure the patient would want to donate that they think the patient wouldn't find dying with some 'discomfort' if it meant saving a couple lives by donating organs? Are palliative care docs going to become persona non grata at the bedside of dcd patients because we'll be perceived as prolonging life via providing symptomatic care? I doubt that, but I'm curious as to where all this could lead, particularly if the findings are repeated/strengthened and dcd becomes more common.
Interesting article from the Boston Globe a few weeks ago with Truog's position on DCD, and the 'arbitrary' nature of brain death.
Trying to figure out if someone who is unconscious is suffering physically is nigh impossible except thru speculation based on personal experience and knowledge of the dying process via education/articles, etc. We can base our speculation on probabilities, but in the end, if we have a significant degree (open to interpretation) of uncertainty, most people I have found are in favor of erring on the side of assuming suffering and treating with appropriate measures. The assumption in that scenario being that all decision makers have come to a open acceptance of death impending for said patient.
I think Nolan's last point is critical to good hospice care, ("...patient is part of a bigger equation...") but realize it is also something that can inhibit symptom control when caregivers insist "They always moan like that. They don't need any medicine."
There is such a stigma that opioids hasten death, that this is at least one quiver to say they can be used appropriately without major effect on the timing of death.
Thanks for all the comments.
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