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Palliative Care and the ICU

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Post Use of Fentanyl and Versed drips in withdrawal
Author: pstark
Date: Jun 17, 2009 12:14 pm
In the case of compassionate extubation, what role (if any) does the use of fentanyl and versed drips play? Particularly, the question of the drips being assistive with the suppression of the respiratory drive rather than for comfort measures?

Just looking for some information regarding practice patterns and how it is viewed.

Thank you for your feedback.

Phyllis Stark
Replies: order by [Date] [Author] [Subject]
Re:Use of Fentanyl and Versed drips in withdrawal (by Deb on 06/17/2009)
I am an ex-ICU nurse, now doing palliative care and very active in the ICU. Our ICU withdrawal order set has a space for opioid of choice, we usually use morphine (relaxes smooth muscle and relieves feeling of air hunger), but fentanyl is not uncommon- many pt's are already on a drip- and sedation of choice, usually versed (for anxiety or agitation). The drips are meant to keep the pt comfortable without regard to the possible side effect of resp suppression. The nurses titrate for comfort. Withdrawal is done with the understanding that the pt will die, due to the disease process, and the family's decision that the current treatment is not what the pt would want under the current circumstances. We do sometimes have pt's who survive withdrawal, and may even go home with hospice.
Re:Use of Fentanyl and Versed drips in withdrawal (by ehargus on 06/18/2009)
One must always keep clear that narcotics (ie. fentanyl or any narcotic for that matter) have two indications----pain and dyspnea. Narcotic usage is not meant to depress the respiratory system. In the conscious patient one can usually sort out the indication for narcotics. In the unconscious patient who is not paralyzed one can usually suspect respiratory difficulty by the pattern of the breathing (ie struggling to take breaths would be presumed dyspnea) and therefore can be so used. Making sure the patient is not paralyzed is absolutely necessary.

Versed or other anxiolytics can and should also be used. Tolerance to versed can be a problem for those on it for significant lengths of time though.
Re:Use of Fentanyl and Versed drips in withdrawal (by SharolHerr on 06/18/2009)
When versed and fentanyl continue to be used with palliative vent withdrawal the intent is to relieve untoward sypmtoms such as anxiety and dyspnea, the intent is not to suppress the respiratory drive. Respiratory suppression may occur when doses need to be escalated to relieve the untoward symptoms. The ethical principal of double effect allows that the greater good may be achieved by use of the medications in the palliative care setting. It is important to have policies, procedures and routine processes in place when using these medications in palliative care. Collaboration with pharmacy and IDT would also reflect due process in establishing the palliative plan of care in these critically ill and complex patients at the time of withdrawal of the support measures. Sharol Herr, RN, BSN, MSEd, CHPN; Nurse Clinician and Education Coordinator; Mount Carmel Health Palliative Care Leadership Center; Columbus, Ohio.

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