LETTER
Reflections on the Doctor's Anguish
Michael J. Burran, MD
1 January 1993 | Volume 118 Issue 1 | Pages 78-80
TO THE EDITOR:
Drs. Edwards and Tolle [1] describe the emotional and ethical issues in withdrawing mechanical ventilation. They emphasize the conflict between the value of sedation to patient comfort and the medical concern about the decrease in respiratory drive and possible hastening of death.
We have found a variation of the "terminal weaning" described by Grenvik [2] to be valuable. Ventilatory support, withdrawn gradually over a few hours using decreasing levels of mechanical ventilation or pressure support, plus small doses of intermediate-duration narcotics and benzodiazepines, allow minimal sedation and respiratory depression consistent with patient comfort. In the fully conscious patient, patient-controlled analgesia devices allow the patient to initially balance sedation and relief of dyspnea. However, unlike Dr. Grenvik's procedure, we do not routinely check arterial blood gases, because the sole goal of our therapy is patient comfort in dying. In our experience, several patients have been able to achieve conscious extubation, allowing them valuable time in the company of their families.
This difference in sedation techniques remains contingent on an appropriate and considered process of decision making as in any withdrawal of life-sustaining therapy.
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Author and Article Information
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Methodist Hospital of Indiana; Indianapolis, IN 46202
1. Edwards MJ, Tolle SW. Disconnecting a ventilator at the request of a patient who knows he will then die: the doctor's anguish. Ann Intern Med. 1992; 117:254-6.
2. Grenvik A. "Terminal weaning"; discontinuance of life-support therapy in the terminally ill patient. Crit Care Med. 1983; 11:394-5.
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