Pain management during the withholding and withdrawal of life support in critically ill patients at the end-of-life: a systematic review and meta-analysis

Abstract

To review and summarize the most frequent medications and dosages used during withholding and withdrawal of life-prolonging measures in critically ill patients in the intensive care unit. Methods: We searched PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Virtual Health Library from inception through March 2019. We considered any study evaluating pharmaceutical interventions for pain management during the withholding or withdrawing of life support in adult critically ill patients at the end-oflife. Two independent investigators performed the screening and data extraction. We pooled data on utilization rate of analgesic and sedative drugs and summarized the dosing between the moment prior to withholding or withdrawal of life support and the moment before death. Results: Thirteen studies met inclusion criteria. Studies were conducted in the United States (38%), Canada (31%), and the Netherlands (31%). Eleven studies were single-cohort and twelve had a Newcastle-Ottawa Scale score of less than 7. The mean age of the patients ranged from 59 to 71 years, 59-100% were mechanically ventilated, and 47-100% of the patients underwent life support withdrawal. The most commonly used opioid and sedative were morphine [utilization rate 60% (95% CI 48-71%)] and midazolam [utilization rate 28% (95% CI 23-32%)], respectively. Doses increased during the end-of-life process (pooled mean increase in the dose of morphine: 2.6 mg/h, 95% CI 1.2-4). Conclusions: Pain control is centered on opioids and adjunctive benzodiazepines, with dosages exceeding those recommended by guidelines. Despite consistency among guidelines, there is significant heterogeneity among practices in end-of-life care.

Perceptions on the current content and pedagogical approaches used in end-of-life care education among undergraduate nursing students: a qualitative, descriptive study

“…Data were collected from fifteen participants through semi-structured interviews between May to August 2020, digitally recorded and transcribed verbatim. Confidentiality and anonymity were ensured, and a semi-structured interview guide was used to elicit information about participants’ experiences of end-of-life care education [ 7 ]. An interview guide was developed based on the literature [ 6 , 27 ] and the clinical expertise of the authors.…”

“…Nurses are expected to provide the highest quality of care for dying patients and their families. Patients at the end-of-life stage have reported experiencing several distressing symptoms such as unsatisfied thirst, dyspnea, chronic pain, anxiety, depression, and difficulty sleeping, as well as delirium and agitation during the final stages of their illness trajectory [ 7 , 8 ]. It is imperative that health care providers understand these signs and symptoms of patient discomfort to help support patients through the dying process as safe, dignified, and comfortable as medically possible [ 9 ].…”

End-of-Life and Palliative Care in a Critical Care Setting: The Crucial Role of the Critical Care Pharmacist

“…The majority of patients transition to end-of-life care while intubated and ventilated, with multiple lines and drains still in situ and often already on high doses of sedatives and analgesics. Given these unique factors, the choice of medication and dose selection in ICU end-of-life care is different from other areas and standardisation is frequently lacking [ 5 ]. The involvement of pharmacists in these challenges, although assumed, has not been investigated in detail.…”

Withholding and withdrawal of life support in critically ill patients at the end of life: pain is not the only symptom to manage

“…We read with interest the recent article presenting a systematic review and meta-analysis summarizing pharmacological pain management during withholding as well as withdrawal of life support for critically ill patients at end-of-life [ 1 ]. We acknowledge the importance of this review and its contribution to end-of-life research as well as clinical management of this vulnerable population.…”