A 75-year-old man is admitted to the intensive care unit due to septic shock and acute respiratory distress syndrome. The patient's medical history is significant for relapsed refractory multiple myeloma and malignant bone pain requiring long-term opioid therapy. Despite a prolonged course of mechanical ventilation, his condition deteriorates; he is transitioned to comfort-oriented care in accordance with his advance directive. The patient is extubated to a simple oxygen face mask. Morphine is administered intravenously to ease air hunger, and glycopyrrolate is given to reduce heavy secretions. Thirty minutes later, he is gurgling loudly. Pulse is 118/min and respirations are 8/min. Oxygen saturation is 90%. Examination reveals a cachectic, obtunded man with irregular, rattling respirations. Pupils are pinpoint bilaterally. Skin is diaphoretic. In addition to suctioning the oropharynx, what is the most appropriate next step in management at this time?

Question

A 75-year-old man is admitted to the intensive care unit due to septic shock and acute respiratory distress syndrome.  The patient's medical history is significant for relapsed refractory multiple myeloma and malignant bone pain requiring long-term opioid therapy.  Despite a prolonged course of mechanical ventilation, his condition deteriorates; he is transitioned to comfort-oriented care in accordance with his advance directive.  The patient is extubated to a simple oxygen face mask.  Morphine is administered intravenously to ease air hunger, and glycopyrrolate is given to reduce heavy secretions.  Thirty minutes later, he is gurgling loudly.  Pulse is 118/min and respirations are 8/min.  Oxygen saturation is 90%.  Examination reveals a cachectic, obtunded man with irregular, rattling respirations.  Pupils are pinpoint bilaterally.  Skin is diaphoretic.  In addition to suctioning the oropharynx, what is the most appropriate next step in management at this time?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c06e_098b_8f63_a7eaa13e738e_MD0005_00 This patient with end-stage malignancy and acute respiratory failure has been transitioned to palliative comfort care, in which the focus shifts toward treatment of symptoms (eg, dyspnea, secretions, pain, anxiety). Close observation for signs and symptoms of distress is the cornerstone of palliative care. After the patient was extubated terminally and given morphine for palliation of dyspnea at the end of life, he developed expected adverse effects, including miosis and respiratory depression. However, he now also exhibits signs of distress (ie, tachycardia, diaphoresis, inability to clear secretions) and active dying, including coma and agonal respirations (ie, irregular, rattling breaths). To be consistent with the predefined goals of care, the patient's comfort should be prioritized over his respiratory status. Administering additional morphine may hasten death, but it still should be given to minimize suffering. This ethical framework is known as the doctrine of double effect: Interventions that have adverse effects (eg, respiratory depression) are justified if they promote patient well-being (eg, allowing for a comfortable death). (Choice B) Although administering a reversal agent such as naloxone may be tempting, doing so would precipitate acute opioid withdrawal. This could cause needless suffering contradictory to the patient's goals of care, especially one who has taken opioids long term for malignant bone pain. (Choices C and D) Noninvasive ventilation (NIV) can be a bridge to recovery in patients with potentially reversible causes of respiratory failure and do-not-intubate instructions. However, it is unlikely to benefit this patient with irreversible underlying disease and continued deterioration; NIV also is contraindicated in patients with decreased consciousness and copious secretions (aspiration risk). An oropharyngeal airway is a C-shaped tube, extending from the gums to the vallecula, that may be used to temporarily improve airway patency in unconscious patients; however, it is highly noxious and conflicts with palliative goals of care. oropharyngeal airway (Choice E) Palliative care interventions are based on signs and symptoms of discomfort (eg, dyspnea, tachypnea). Diagnostic tests may cause unnecessary discomfort (eg, pain during venipuncture or positioning for chest x-rays). Although the tests may reveal abnormalities, their results usually do not influence clinical symptom management. Educational objective: Opioids are used to relieve pain and dyspnea at the end of life. In actively dying patients with comfort-oriented goals of care, opioids may be used to promote comfort despite hastening the dying process.

A 75-Year-Old Man Is Admitted to the Intensive Care Unit