Correspondence

Neuromuscular Blockade at the End of Life

N Engl J Med 2000; 342:1921-1922June 22, 2000

Article

To the Editor:

The complex ethical and emotional aspects of withdrawing ventilatory support from critically ill patients were well presented by Truog et al. (Feb. 17 issue)1 in their Sounding Board article on the role of neuromuscular blockade in this difficult situation. We strongly agree that neuromuscular blocking agents must never be used in the absence of adequate sedation and analgesia. Unfortunately, this goal is not consistently attained in practice, since as many as one third of patients who receive these medications recall the experience.2 Truog et al. appropriately differentiate between actual patient comfort and the appearance of patient comfort in situations in which neuromuscular blockade precludes assessment. We agree that whenever possible, neuromuscular function should be restored before the withdrawal of ventilatory support. In the rare event that an extended period is required for this to occur, Truog et al. suggest that clinical skill and judgment should guide the administration of sedatives and analgesics. We would like to add that the use of the electroencephalographically based bispectral index3 may provide valuable and complementary information in this situation, increasing the likelihood that real sedation and comfort will be achieved.

The bispectral index has been used extensively during neuromuscular blockade of patients in the operating room, and a range of scores has been identified at which patient awareness and recall are unlikely and that correlates well with assessments of hypnotic-drug effects.3 We have used this test in patients in the intensive care unit, and we also identified a range of scores that were associated with the absence of wakefulness among patients and confirmed the correlation between scores and the results of a subjective assessment of wakefulness among 63 adult patients.4 Campbell et al.5 used the bispectral index during the withdrawal of ventilatory support in 11 adult patients; although none of these patients were receiving neuromuscular blocking agents, a strong correlation was again noted between the bispectral-index scores and the results of subjective assessments of patient comfort.

Richard R. Riker, M.D.
Gilles L. Fraser, Pharm.D.
Maine Medical Center, Portland, ME 04102

5 References

1. 1

   Truog RD, Burns JP, Mitchell C, Johnson J, Robinson W. Pharmacologic paralysis and withdrawal of mechanical ventilation at the end of life. N Engl J Med 2000;342:508-511
   Full Text | Web of Science | Medline

2. 2

   Wagner BK, Zavotsky KE, Sweeney JB, Palmeri BA, Hammond JS. Patient recall of therapeutic paralysis in a surgical critical care unit. Pharmacotherapy 1998;18:358-363
   Web of Science | Medline

3. 3

   Rosow C, Manberg PJ. Bispectral index monitoring. Anesthesiol Clin North Am 1998;2:89-107
   

4. 4

   Simmons LE, Riker RR, Prato BS, Fraser GL. Assessing sedation during intensive care unit mechanical ventilation with the Bispectral Index and the Sedation-Agitation Scale. Crit Care Med 1999;27:1499-1504
   CrossRef | Web of Science | Medline

5. 5

   Campbell ML, Bizek KS, Thill M. Patient responses during rapid terminal weaning from mechanical ventilation: a prospective study. Crit Care Med 1999;27:73-77
   CrossRef | Web of Science | Medline

To the Editor:

Truog et al. discuss the use of neuromuscular blocking agents near the end of life from a perspective of ethics and in a logical and organized manner. The subject needs more discussion, and the authors are to be applauded for bringing this point forward in the Journal. One must realize, however, that there is also a legal point of view with respect to this subject: the view of many medical examiners is that euthanasia of patients is an act of homicide, particularly if the patients had not been receiving neuromuscular blocking agents as part of treatment before the decision was made to use them at the end of life. Readers should be aware of these other issues; when it comes to euthanasia, it is misleading to ignore the legal aspects, and ethical issues cannot be discussed without mentioning legal issues, and vice versa. Attempts to separate the two are probably a factor in the poor rate of compliance in disclosing the use of these agents to a medical examiner's office. If the person who reports a death does not fully disclose to the medical examiner the use of neuromuscular blocking agents at the end of life, that person could be accused by local law-enforcement agencies of concealing a homicide, not to mention the accusations of homicide that could be leveled against the health care providers who administered the drugs and subsequently removed life support or the view of members of state licensing agencies who are notified of such actions.

William B. Rohr, M.D.
Collin County Medical Examiner's Office, McKinney, TX 75069

Author/Editor Response

The authors reply:

To the Editor: Although we believe that in most cases clinicians should try to minimize the number of bedside monitors at the time of withdrawal of life support, we agree with Riker and Fraser that the bispectral index may be useful in certain circumstances, such as when the patient is paralyzed with neuromuscular blocking agents.

Our intention was not to provide a legal analysis of the questions raised by our article, and we would disagree that readers of the Journal are likely to be misled into assuming that because legal issues were not discussed, they do not exist. We argued from an ethical perspective that neuromuscular blocking agents should never be introduced at the time of withdrawal of ventilatory support, and we would agree with Rohr that this is not an acceptable practice. In the limited circumstances and under the conditions that we describe in our article, however, we do not believe that the withdrawal of ventilatory support from a patient who remains paralyzed after receiving neuromuscular blocking agents should be considered an act of euthanasia or homicide.

Robert D. Truog, M.D.
Jeffrey P. Burns, M.D., M.P.H.
Christine Mitchell, R.N.
Judy Johnson, J.D.
Walter Robinson, M.D., M.P.H.
Children's Hospital, Boston, MA 02115

Citing Articles (4)

Citing Articles

1. 1

   Michael H. Hooper, Timothy D. Girard. (2011) Sedation and Weaning from Mechanical Ventilation: Linking Spontaneous Awakening Trials and Spontaneous Breathing Trials to Improve Patient Outcomes. Anesthesiology Clinics 29:4, 651-661
   CrossRef

2. 2

   Michael H. Hooper, Timothy D. Girard. (2009) Sedation and Weaning from Mechanical Ventilation: Linking Spontaneous Awakening Trials and Spontaneous Breathing Trials to Improve Patient Outcomes. Critical Care Clinics 25:3, 515-525
   CrossRef

3. 3

   Mohamed Y. Rady, Joseph L. Verheijde, Muna S. Ali. (2009) Islam and End-of-Life Practices in Organ Donation for Transplantation: New Questions and Serious Sociocultural Consequences. HEC Forum 21:2, 175-205
   CrossRef

4. 4

   Sharon Reynolds, Andrew B. Cooper, Martin McKneally. (2007) Withdrawing Life-Sustaining Treatment: Ethical Considerations. Surgical Clinics of North America 87:4, 919-936
   CrossRef