eTABLE 19 1 Medications Commonly Used for Pain and Distress at the End of Lifea Medication Routes Starting Dose Notes Opioids Morphine PO, SL, PR, SQ, IV 0 05–0 1 mg/kg every 3–4 h Infusion 0 01–0 03[.]
Trang 1eTABLE
19.1 Medications Commonly Used for Pain and Distress at the End of Lifea
Opioids
Morphine PO, SL, PR, SQ, IV 0.05–0.1 mg/kg every 3–4 h
Infusion: 0.01–0.03 mg/kg/h Renally excreted; causes histamine release Hydromorphone PO, IV, SQ, SL 0.015 mg/kg every 3–4 h
Infusion: 0.003 mg/kg/h Fentanyl IV, SQ, buccal, nasal,
patch 0.5-1 mcg/kg every 30 min Infusion: 1 µg/kg/h Transdermal patches available in 12.5, 25, 50, 75 and 100 µg/h Methadone PO, IV 0.05–0.1 mg/kg every 6–12 h initially,
then decrease frequency Long acting and may accumulate; may be adjunctive for neuropathic pain via NMDA effects; prolongs
QT interval; multiple drug interactions
Benzodiazepines
Midazolam PO, IV, SC 0.05–0.1 mg/kg every 2–4 h
Infusion: 0.03–0.1 mg/kg/h Onset of action within minutes when given IV Lorazepam PO, IV, IM 0.025–0.1 mg/kg every 4–8 h Less hypotension than midazolam, slightly slower
onset Diazepam PO, PR 0.05–0.2 mg/kg every 6-12 h IM and IV formulations available but rarely used due to
pain/phlebitis; IV form may also be given PO or PR
Other Sedatives and Adjuncts
effects
day, then reassess
a All doses are starting doses for patients not previously exposed and may need to be escalated to much higher levels.
IM, Intramuscular; IV, intravenous; NMDA, N-methyl-D-aspartate; PO, oral; PR, per rectum; SL, sublingual; SQ, subcutaneous.
161.e1
Trang 2Seizures can also occur at the end of life, for which
benzodiaze-pines are a good first-line agent Levetiracetam or valproate are
sometimes used as prophylaxis against seizures in patients at high
risk (e.g., with brain tumors).58
Bowel Obstruction
Bowel obstruction is a particularly difficult situation to manage
Decompression with nasogastric drainage may improve
symp-toms Relieving constipation is often important Steroids may be
beneficial if the obstruction is due to a mass Motility agents can
be helpful, but they may also increase pain Octreotide
(intrave-nous or subcutaneous) has been used to decrease intestinal
secre-tions and may improve symptoms such as vomiting.60 Palliative
surgery can be considered, but the degree and duration of benefits
versus burdens should be carefully weighed.59
Palliative Sedation
Rarely, symptoms may remain uncontrolled at the end of life
de-spite maximal medical management In such circumstances,
pal-liative sedation may be considered Palpal-liative sedation is “the use
of sedative medications to relieve intolerable suffering from
refrac-tory symptoms by a reduction in patient consciousness.”61,62
Benzodiazepines, barbiturates, dexmedetomidine, or propofol can
be used Additionally, propofol has advantageous effects against
nausea, pruritus, seizures, and myoclonus, while
dexmedetomi-dine is useful because it does not cause respiratory depression
Sedation to unconsciousness can be justified when symptoms
can-not be managed by other means and death is considered
immi-nent (e.g., within hours to days) Protocols have been published
that guide the implementation of palliative sedation, which
in-clude prerequisite consensus by an interdisciplinary team that
symptoms are truly refractory and that the patient is imminently
dying of a terminal illness.63
Care of Family and Staff after a Child’s Death
The death of a child is a tragic event that affects all who are
touched by it Grief support is a crucial part of the ongoing care
that bereaved families need after their child dies; these services
are typically provided by referral to a community- or
hospital-based bereavement program Such programs provide ongoing
support and frequent assessments to identify complicated grief
when it occurs Bereaved families of chronically ill children
of-ten describe a sense of “double loss,” both for their child and for
their medical team who cared for them over the course of
months or years.64
Staff members in the ICU are also impacted by the death of a
child and are at risk for compassion fatigue and burnout due to
repeated exposure to secondary trauma.65 The American College
of Critical Care Medicine Task Force guidelines for support of the patient and family in the ICU setting recommend structured sup-port mechanisms for staff, such as debriefing sessions,66 which can
be facilitated by social work, spiritual care, or palliative care For some individuals, these sessions provide a safe forum to discuss their feelings about a particular patient or experience, which can help process grief Others may benefit from developing personal-ized ways to process stress or grief, which can include any number
of activities, such as exercise, reflective writing, outdoor activities, engaging in a spiritual practice, or meeting with a counselor or therapist regularly In addition, some staff members choose to send condolence letters or attend memorial services for children
as a way to further support the family, honor the memory of the child, and process their own grief.
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neonatal intensive care units Pediatr Clin North Am
2007;54:773-785
e1
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Guide-lines on foregoing life-sustaining medical treatment Pediatrics
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Trang 5Abstract: Pediatric intensivists must develop a high level of
com-petency in core palliative care skills, such as communication,
shared decision-making, appropriate limitation of interventions,
compassionate extubation, and symptom management
Intensiv-ists must also know when to consult a palliative care team for
secondary palliative care support, such as in the case of complex
decision-making, advanced symptom management, need for en-hanced family support, or transitioning a patient to hospice.
Key Words: palliative care, communication, shared decision-making, compassionate extubation, symptom management, grief support, hospice