Tuesday, July 10, 2007

Pancuronium = Pain relief? For whom?

Kevin, MD pointed out this story of death in a UK Neonatal ICU.

A British medical consultant (the equivalent of a neonatologist in the US), was treating 2 very pre-term babies whose condition had become hopeless - or nearly so. With the parents in agreement, he removed the babies from their ventilators in order to permit them to die. I don't have any issues with this part of the story. It's something that is done more frequently than most people know. It is not ethically different to withdraw life support than never to start it - more difficult for the families, but not different ethically.

The babies were given morphine to help keep them comfortable -- again, the ethical choice. Suffering should not be permitted in the course of dying if it is in our power to prevent it. The dose was not too large. If anything, he gave too small a dose, because the babies began agonal breathing. Gasping. If they were adequately sedated, they wouldn't be uncomfortable, but there is simply no way for them to tell us, so their parents were understandably disturbed by the gasping.

The physicians choice, apparently, was not to administer more morphine, but instead to give a drug called pancuronium (Pavulon) which paralyzes the muscles. It doesn't provide ANY relief from any sort of distress. It stops the breathing and almost certainly speeds up the dying process. Death by suffocation.

The article does a fairly good job of laying out the realities of dying infants and the distress of their parents. I have a great deal of sympathy for the parents. I am horrified at the physician's choice - not so much because it hastened death, but because of the mechanism. Imagine being paralyzed, but fully aware. Just as we have no way of knowing if those babies were suffering before he gave them the Pavulon, we have no way of knowing if they had any relief from suffering. They may have been totally aware of being unable to breathe. Worse than gasping? I don't know, but it's not something I'd want to find out.

He may have been treating the parents' distress, and possibly his own, but he did NOTHING for that baby by giving the Pavulon.

I have friends who were present when a neonatologist suggested using Pavulon when a baby was taken off the ventilator. The nurses in the room made it quite clear that this was not an acceptable course of action, and he prescribed morphine in doses adequate to keep the baby comfortable instead. I wasn't present, so I don't know how much gasping occurred, but the parents were assured that the baby had enough medication to be comfortable in spite of any gasping. Death was not immediate, but did not drag on for hours either, according to the nurses present.

I would love to know what conversation took place between the British physician and the nurses there. Did they try to persuade him to take another course of action, or did they simply watch and then report him afterwards? I sincerely hope it was the former and not the latter.

So what is Pavulon used for? It is used - with the patient intubated, ventilated, and under general anesthesia or very heavy sedation - to achieve complete muscle relaxation - paralysis, if you prefer, because it prevents voluntary muscle movement. When the patient is under general anesthesia or heavily sedated, this can be theraputic. It is necessary for many kinds of surgery and it is beneficial when there is no other way to ventilate a patient who is struggling in spite of heavy sedation. Without the anesthesia or sedation? It's called anesthesia awareness, and adults who've been through it are traumatized.

For more on the subject, see Geena's post at Code Blog and another by Kirsti Dyer, MD at NICU Parent Support Blog. Finally, read Dr. Crippen's thoughts at NHS Blog Doctor.


geena said...

I just blogged about this myself and hopped on over here to see what you had to say about it.

I see we're in agreement.

But doesn't Pavulon also prevent INvoluntary muscle movement?

ERnursey said...

That is dreadful. Imagine the agony those parents are suffering knowing that their beloved infant died of slow suffocation, awake and aware.

Judy said...

I sincerely hope the parents don't know. Odds are they'll find out with this court case, though.

Yes and no. Yes, it will stop involuntary movement of voluntary muscle groups. No, it won't stop involuntary muscle movement (cardiac, for example)which is what I was thinking. Could have phrased that better, but I was more than a little disturbed at his choice of drugs.

Wabi said...

I experienced anesthesia awareness during a cascade of complications during a surgery last year. I have written on my own blog about the horror of feeling as though I was suffocating while conscious but unable to move or tell anyone that I was in pain. I truly thought I was dying, and that is not something you quickly shake off when you leave the hospital. I for one had panic attacks and insomnia afterwards for awhile.

In my case, the sense of being unable to breathe was terrifying, but ultimately false -- I had a breathing tube inserted that was giving me oxygen, despite my perception. But if a baby was given a drug that paralyzed involuntary muscles, then the poor child would ACTUALLY be suffocating. Infants are not capable of the sort of frantic conscious thoughts about husbands and children that I had before I finally blacked out again, but I think infants certainly would still feel that panic and discomfort just the same. Their last sensations would be that of struggling, and of fear.

Horrifying, if this is indeed what that particular drug does.

Anonymous said...

Diprivan would certainly be a better choice.

Judy said...

Diprivan, AKA Propofol. Definitely a better choice than pancuronium, IMO. The problem would be that it isn't commonly used in NICUs, so the nurses might not be comfortable. OTOH, a continuous fentanyl or morphine infusion would seem appropriate and something with which NICU nurses would have more experience.

Anonymous said...

i think that what this doctor did is horrible because he should try to keep the babies confortable during the process of dying not just try to huury the death also parents should be kept away of the room when they have to take this courses of action so the doctor can do the best on keeping the babies confortable and the parents don't go thruogh that strees of seeing their chindren die

Pain relief

Judy said...

Sometimes parents can't handle the stress of a baby's death. At my hospital, one of the nurses will generally hold the baby when death is imminent if the parents can't.

We do encourage them to stay and try to provide emotional support for them. Hard as it is to be present when a baby dies, I cannot imagine the pain of being forbidden to be there.