Narcotics, Benzodiazepines, and Hastening Death after Withdrawal of Life Support

Abstract & Commentary

Synopsis: This study found no evidence that the use of narcotics or benzodiazepines to treat discomfort after the withdrawal of life support hastens death in critically ill patients at our center. Clinicians should strive to control patient symptoms in this setting and should document the rationale for escalating drug doses.

Source: Chan JD, et al. Chest. 2004;126:286-293.

A retrospective chart review was conducted over an 8-month time period to determine whether the doses of narcotics and benzodiazepines were associated with the length of time between removal of mechanical ventilation and death among ICU patients for whom life sustaining treatments were being withdrawn. The study, conducted at a university affiliated level I trauma center on the West Coast, included 75 ICU patients with a mean age of 59 years. Patient diagnoses included intracranial hemorrhage (37%), trauma (27%), acute respiratory failure (27%), and acute renal failure (20%).

Results revealed that once the process of ventilator withdrawl was initiated, patients died within a median of 35 minutes (range, 1-890 minutes). Cumulative amounts of benzodiazepines and narcotics were calculated during 3 time periods: 1) 24 hours before death, 2) time from 1 hour after ventilator withdrawl until time of death, and 3) 2-hour period prior to death (see Table, below). Morphine and lorazepam were the primary agents used and were administered by both bolus and continuous infusion during life support withdrawl. When life-sustaining therapy was anticipated, the doses of narcotics and benzodiazepines increased significantly (P < 0.001). Multivariate linear regression modeling demonstrated no statistically significant relationship between either benzodiazepine or narcotic dose during the time interval from 1 hour prior to ventilator withdrawl until death and the outcome of time to death from ventilator discontinuation.

Comment by Karen L. Johnson, PhD, RN

Critical care physicians and nurses may withhold or limit the use of narcotics and benzodiazepines at the end of life for fear that others may perceive they are hastening death. The results of this study add to an increasing body of knowledge that this perception is not reality. This investigation found no evidence that the use of narcotics and benzodiazepines after withdrawl of life support hastened death in this sample of critically ill patients. Chan and colleagues did not find a relationship between an increased narcotic dose and time to death during the last 2 hours of life (P = 0.11). Chan et al did find a relationship, however, between the dose of benzodiazepines and death: increased dosages were associated with an increase in time to death! On average, every 1 mg/hour increase in benzodiazepine use corresponded to a statistically significant increase in duration of time between ventilator withdrawal and death (P = 0.015). Although admitting that these results need to be confirmed in a larger study, Chan et al offer 2 possible explanations: 1) patients who survive longer may have developed benzodiazepine tolerance and therefore required a larger dose, and 2) the anxiolytic effect of benzodiazepines may have achieved a calming effect in these dying patients, without the compromise of hastening death.

Another interesting (yet not surprising) finding was justifications for medication dosage increase during these times were not consistently documented in the medical record using pain or sedation scores. Chan et al (or therefore anyone else reviewing the chart) could not determine whether the levels of analgesia and sedation were appropriate. Granted, assessing pain and sedation in these patients is difficult due to impaired cognition and communication. However, doesn’t the lack of documentation of the need for increasing the dose of these drugs fuel the perception that they are given to hasten death? The only way to eliminate the perception (or the fear of the perception) is for clinicians to document the rationale for escalating drug doses. The perception that narcotic and benzodiazepine use hastens death can be eliminated by a 2-pronged approach: 1) More studies, such as this one, that demonstrate there is no relationship between the use of these drugs and time of death, and 2) thorough documentation in the medical record on the rationale for use and dose of these drugs. Only then will perception equal reality that the use of narcotics and benzodiazepines after withdrawl of life support limits discomfort during end of life care.

Karen Johnson, PhD, RN, School of Nursing University of Maryland, is Associate Editor for Critical Care Alert