Last Days of Life (PDQ®): Supportive care - Health Professional Information [NCI] - Ethical Issues
Paralytic agents have no analgesic or sedative effects, and they can mask patient discomfort. These neuromuscular blockers should be discontinued before extubation. Guidelines suggest that these agents should never be introduced when the ventilator is being withdrawn; in general, when patients have been receiving paralytic agents, these agents should be withdrawn before extubation. The advantage of withdrawal of the neuromuscular blocker is the resultant ability of the health care provider to better assess the patient's comfort level and to allow possible interaction between the patient and loved ones. One notable exception to withdrawal of the paralytic agent is when death is expected to be rapid after the removal of the ventilator and when waiting for the drug to reverse might place an unreasonable burden on the patient and family.
Regardless of the technique employed, the patient and setting must be prepared. Monitors and alarms should be turned off, and life-prolonging interventions such as antibiotics and transfusions should be discontinued. Family members should be given sufficient time to make preparations, including making arrangements for the presence of all loved ones who wish to be in attendance. They should be given information on what to expect during the process; some may elect to remain out of the room during extubation. Chaplains or social workers may be called to provide support to the family.
Some families may need continuous information and professional guidance when palliative sedation is used, and this need increases with the duration of the sedation. Individuals or groups outside the family and health care team may have strong opinions about palliative sedation and may offer unsolicited guidance that conflicts with what the patient desires. Concerns identified in a study conducted in The Netherlands relate to the following:
- Aim of continuous sedation.
- Patient well-being.
- Family well-being.
The use of palliative sedation for psychosocial and existential symptoms can be particularly controversial. The clinician may face many ethical and clinical questions—questions that are more easily resolved in the case of palliative sedation for pain and physical symptoms. Useful resources include the framework for the use of sedation in palliative care recommended by the European Association for Palliative Care  and the position statement developed by the American Academy of Hospice and Palliative Medicine.
For example, the ethical basis for the use of terminal sedation (double effect) is less clearly applicable in the case of psychiatric symptoms. Under the principle of double effect, the intended effect (relieving psychological suffering) would be considered allowable as long as any risks or negative effects (i.e., shortened survival) are unintended by the health care professional. The difficulty arises because the principle only discusses the professional's intention, when it is the patient's intention that can be unclear and potentially problematic. Is the depressed patient who no longer wants to suffer depressive symptoms asking only for that relief, or does the patient also intend to ask the professional to shorten his or her life? A clinician who feels uncomfortable in such situations may wish to seek guidance from his or her ethics committee.