Exoneraciones y beneficios tributarios

Requests from appropriately informed and competent patients or their surrogates for withdrawal of life-sustaining interventions must be respected. Limitation of life-sustain- ing interventions prior to death is an increasingly common practice in intensive care units. The withdrawal of life- sustaining interventions, such as mechanical ventilation, must be approached carefully to avoid needless patient suffering and distress for those in attendance. Clinicians should educate the patient and family about the expected course of events and the difficulty of determining the pre- cise timing of death after withdrawal of interventions. Sedative and analgesic agents should be administered to ensure patient comfort even at the risk of respiratory depression or hypotension. Scopolamine (10 mcg/h subcu- taneously or intravenously, or a 1.5-mg patch every 3 days), glycopyrrolate (1 mg orally every 4 hours), or atropine (1% ophthalmic solution, 1 or 2 drops sublingually as often as every hour) can be used for controlling airway secretions and the resultant “death rattle.” A guideline for withdrawal of mechanical ventilation is provided in Table 5–7.

»Psychological, Social, & Spiritual Issues

Dying is not exclusively or even primarily a biomedical event. It is an intimate personal experience with profound psychological, interpersonal, and existential meanings. For many people at the end of life, the prospect of impending death stimulates a deep and urgent assessment of their identity, the quality of their relationships, the meaning and purpose of their existence, and their legacy.

A. Psychological Challenges

In 1969, Elisabeth Kübler-Ross identified five psychologi- cal reactions or patterns of emotions that patients at the end of life may experience: denial and isolation, anger, bargaining, depression, and acceptance. Not every patient will experience all these emotions, and typically not in an orderly progression. In addition to these five reactions are the perpetual challenges of anxiety and fear of the unknown. Simple information, listening, assurance, and support may help patients with these psychological chal- lenges. In fact, patients and families rank emotional sup- port as one of the most important aspects of good end-of-life care. Psychotherapy and group support may be beneficial as well.

Despite the significant emotional stress of facing death, clinical depression is not normal at the end of life and should be treated. Cognitive and affective signs of depres- sion (such as hopelessness or helplessness) may help distin- guish depression from the low energy and other vegetative signs common with end-stage illness. Although traditional antidepressant treatments such as selective serotonin reup- take inhibitors are effective, more rapidly acting medica- tions, such as dextroamphetamine or methylphenidate (in doses used for sedation described earlier in this chapter), may be particularly useful when the end of life is near or while waiting for other antidepressant medication to take effect. Oral ketamine is emerging as a promising, rapid- onset treatment for anxiety and depression at the end of life. Some research suggests a mortality benefit from treat- ing depression in the setting of serious illness.

B. Social Challenges

At the end of life, patients should be encouraged to dis- charge personal, professional, and business obligations. These tasks include completing important work or per- sonal projects, distributing possessions, writing a will, and making funeral and burial arrangements. The prospect of death often prompts patients to examine the quality of their interpersonal relationships and to begin the process of saying goodbye (Table 5–8). Dying may intensify a patient’s need to feel cared for by the clinician and the need for clinician empathy and compassion. Concern about estranged relationships or “unfinished business” with

significant others and interest in reconciliation may become paramount at this time.

C. Spiritual Challenges

Spirituality is the attempt to understand or accept the underlying meaning of life, one’s relationships to oneself and other people, one’s place in the universe, one’s legacy, and the possibility of a “higher power” in the universe. Spirituality is distinguished from particular religious prac- tices or beliefs and is generally considered a universal human concern.

Unlike physical ailments, such as infections and frac- tures, which usually require a clinician’s intervention to be treated, the patient’s spiritual concerns often require only a clinician’s attention, listening, and witness. Clinicians can inquire about the patient’s spiritual concerns and ask whether the patient wishes to discuss them. For example, asking, “How are you within yourself?” or “Are you at peace?” communicates that the clinician is interested in the patient’s whole experience and provides an opportunity for the patient to share perceptions about his or her inner life. Questions that might constitute an existential “review of systems” are presented in Table 5–9. Formal legacy work and dignity therapy have been shown to be effective in

Table 5–9. An existential review of systems. Intrapersonal

What does your illness/dying mean to you? What do you think caused your illness? How have you been healed in the past?

What do you think is needed for you to be healed now? What is right with you now?

What do you hope for? Are you at peace?

Interpersonal

Who is important to you?

To whom does your illness/dying matter?

Do you have any unfinished business with significant others?

Transpersonal

What is your source of strength, help, or hope? Do you have spiritual concerns or a spiritual practice? If so, how does your spirituality relate to your illness/dying,

andhow can I help integrate your spirituality into your health care?

What do you think happens after we die? What purpose might your illness/dying serve? What do you think is trying to happen here?

Table 5–7. Guidelines for withdrawal of mechanical ventilation.

1. Stop neuromuscular blocking agents.

2. Administer opioids or sedatives to eliminate distress. If not already sedated, begin with fentanyl 100 mcg (or morphine sulfate 10 mg). Provide repeated boluses as needed during the process of withdrawing mechanical ventilation. Patients who require repeated boluses may benefit from a continuous infu- sion of fentanyl 100 mcg/h intravenously (or morphine sulfate 10 mg/h intravenously). Distress is indicated by RR > 24, nasal flaring, use of accessory muscles of respiration, HR increase > 20%, MAP increase > 20%, grimacing, clutching.

3. Discontinue vasoactive agents and other agents unrelated to patient comfort, such as antibiotics, intravenous fluids, and diagnostic procedures.

4. Decrease Fio2 to room air and PEEP to 0 cm H2O.

5. Observe patient for distress. If patient is distressed, increase opioids by repeating bolus dose and increasing hourly infusion rate by 50 mcg fentanyl (or 5 mg morphine sulfate),1 _then

return to observation. If patient is not distressed, place on T piece and observe. If patient continues without distress, extubate patient and continue to observe for distress.

1_{Ventilatory support may be increased until additional opioids}

have effect.

RR, respiratory rate; HR, heart rate; MAP, mean airway pressure; Fio2,fraction of inspired oxygen; PEEP, positive end-expiratory pres-

sure.

Adapted, with permission, from San Francisco General Hospital Guidelines for Withdrawal of Mechanical Ventilation/Life Support.

Table 5–8. Five statements often necessary for the completion of important interpersonal relationships.

1. “Forgive me.” 2. “I forgive you.” 3. “Thank you.” 4. “I love you.” 5. “Goodbye.”

(An expression of regret) (An expression of acceptance) (An expression of gratitude) (An expression of affection) (Leave-taking)

Reprinted, with permission, from Byock I. Dying Well: Peace and Possibilities at the End of Life. New York: Riverhead Books, 1997.

improving quality of life and spiritual well-being. Compre- hensive care includes support from clinicians and engage- ment with religious communities and professional chaplains.

While dying may be a period of inevitable loss of physi- cal functioning, the end of life also offers an opportunity for psychological, interpersonal, and spiritual develop- ment. Individuals may grow—even achieve a heightened sense of well-being or transcendence—in the process of dying. Through listening, support, and presence, clinicians may help foster this learning and be a catalyst for this transformation. Rather than thinking of dying simply as the termination of life, clinicians and patients may be guided by a developmental model of dying that recognizes a series of lifelong developmental tasks and landmarks and allows for growth at the end of life.

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