by Joseph J. Schlesinger (Assistant Professor, Department of Anesthesiology and Division of Critical Care Medicine, Vanderbilt University School of Medicine)
Use of opioids at the end-of-life, particularly when care is being withdrawn, can tread a fine ethical line.
A known effect of opioid administration is decreased respiratory drive and minute ventilation (the amount of gas inhaled into the lungs per minute) as well as increased sedation. This presents a challenge at the end-of-life where providing patient comfort and relieving suffering may be at odds with preserving adequate ventilation.
A Patient Story
Esther (not her real name) is a 70-year-old Kenyan woman who had no history of having received any preventative (primary) care. She presented to a missionary hospital very ill from Plasmodium falciparum malaria which had progressed to end-stage renal disease (ESRD). Initially, the patient’s family did not want dialysis as services were not available at the missionary hospital and it necessitated transfer two hours away to a tertiary care center in Nairobi.
Several days later, the family wished to pursue dialysis, but the ESRD had progressed to the point where dialysis would have been ineffective, leaving kidney transplantation as the only, but not possible, option. Ventilator-associated pneumonia (VAP) also developed during this time period.
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