Critical Care / Emergency / Trauma

Last Breath: The ethics of pharmacologic paralysis

Clinicians agree that neuromuscular blockers must not be used without sedation and analgesia, but they disagree on whether or not to restore neuromuscular function before life support is withdrawn. Some clinicians continue administering neuromuscular blockers or don’t wait for their effects to wear off before withdrawing life support once the medical team and family have decided to stop aggressive support. Others think that receiving neuromuscular blockers during withdrawal of mechanical ventilation in the absence of neuromuscular function is unethical. This article examines this dilemma.

Understanding neuromuscular blockers
Neuromuscular blockers are used with anesthesia to eliminate movement during surgery. In the intensive care unit (ICU), they may be used to facilitate mechanical ventilation by suppressing spontaneous breathing. The half-life of neuromuscular blockers ranges from minutes to hours, but in patients with hepatic or renal dysfunction, reversal can be prolonged for several days.

Neuromuscular blockers have no sedative or analgesic effect and thus shouldn’t be used without sedation and analgesia.

Questions to consider
When faced with the dilemma of whether to wait for neuromuscular function to be restored before life support is withdrawn, consider these questions:

• Will the patient’s comfort be maintained?
• Is it appropriate to ask a family, once they have decided to withdraw mechanical ventilatory support, to wait hours, days, or longer until the drug’s effects dissipate?
• What will be the ultimate cause of death—the underlying disease or the drug?
• What benefits will the continued administration of the drug provide during the withdrawal of life support?
• Is the primary purpose of administering neuromuscular blockers to benefit the patient or the family at the bedside?

Continuing neuromuscular blockade
Supporters believe that neuromuscular blockers may be continued during mechanical ventilation withdrawal in patients who are already receiving them as part of their therapeutic regimen. These clinicians are convinced that waiting for the effects of neuromuscular blockers to reverse or wear off before withdrawing life support isn’t necessary. They also are aware that neuromuscular blockers don’t offer sedative or analgesic effects and know that diligence is needed to ensure patient comfort at the end of life. These drugs will prevent agonal respirations in dying patients, but no evidence shows that this respiratory pattern indicates patient discomfort.


Clinicians routinely use clinical parameters to assess patients’ level of comfort and to titrate sedation and analgesia administration in patients receiving neuromuscular blockers in the ICU. This practice shouldn’t change for patients at the end of life. One study showed that patients with altered mental status or coma who weren’t receiving concomitant neuromuscular blockers had little or no analgesia or sedation requirements at the end of life. These data can be extrapolated to those patients with altered mental status or coma who are under the effects of neuromuscular blockers. Adjunct technology, which uses an electroencephalographic signal to assess comfort—as in bispectral analysis—can be used to ensure patient comfort and sedation.

What about the family?
Once a family determines that the burdens of treatment outweigh the benefits, there should be no delay in assisting family members to relieve their loved one’s suffering.

Consider this example: A patient who suffers catastrophic neurologic damage with no chance for meaningful recovery needs a neuromuscular blocker to facilitate an unconventional mode of ventilation—high frequency oscillatory ventilation. The family wants to end his suffering by immediately disconnecting the ventilator. Although the continuous infusion of the neuromuscular blocker is stopped, the patient continues to receive its therapeutic effects. After the patient receives sedation and analgesia, the ventilator is withdrawn. The patient dies within 3 minutes.

The family is left with the inevitable burden of loss, yet the loss is lessened by the peaceful and rapid death of their loved one. After all the suffering the patient endured, he was ultimately able to die in a state of serenity, providing a sense of relief to his family.

Supporters believe that death is caused by the underlying disease, such as respiratory or cardiac failure, not the continued administration of neuromuscular blockers during withdrawal of mechanical ventilation. These clinicians insist that once the decision to discontinue life support is made, the family’s suffering should be relieved in a timely manner.

Ending neuromuscular blockade
Opponents of using neuromuscular blockers for mechanical ventilation withdrawal believe that the blockade should be reversed or the effects allowed to wear off, so neuromuscular function can be restored before life support is withdrawn. These clinicians believe withdrawal of life support in the absence of paralysis is desirable whenever possible. Also, they understand that neuromuscular blockers have no sedative or analgesic properties, thus negating any therapeutic purpose. Drug-induced paralysis impedes optimal assessment of the patient’s comfort during the withdrawal process, possibly resulting in unnecessary and unrecognized suffering by the patient.

A patient under the effects of a neuromuscular blocker at the time of ventilator withdrawal may appear comfortable to family because the patient is unable to move or gasp. However, the patient’s discomfort level can’t be determined. In a study of patient recall after pharmacologic paralysis, four patients (36%) recalled the experience. One described feeling constant discomfort while being unable to move.

Pain assessment relies on monitoring the level of consciousness, facial expressions, and respiratory patterns. Pharmacologic paralysis impedes pain assessment in end-of-life patients because these patients can’t communicate, can’t breathe independently, and may not produce facial expressions. In fact, neuromuscular blockers may mask the signs of acute air hunger associated with withdrawal of ventilatory support, leaving the patient to endure the agony of suffocation in silence and isolation. Bispectral analysis can provide data to help assess patient comfort but is intrusive, and an impractical tool for end-of-life patients.

Nurses who support restoring neuromuscular function before life-support withdrawal believe that the patient’s comfort comes first, the family’s second. Also, supporters believe that withdrawing mechanical ventilation from a patient who’s pharmacologically paralyzed is the same as euthanizing a patient because the drugs are the cause of death.

What’s the intent?
Is the intent of continuing neuromuscular blockers during withdrawal of life support to hasten patient death or to relieve end-of-life symptoms?

Current ethical and legal guidelines emphasize administering analgesics and sedatives in dosages that provide comfort and relieve pain during the withdrawal of treatment. The purpose of using a neuromuscular blocker is to eliminate the patient’s ability to breathe spontaneously and allow adequate ventilation. During life-support withdrawal, the main focus should be on providing patient comfort, not supporting ventilation.

Continuing dilemma
The ethical dilemma of whether to maintain a therapeutic regimen of neuromuscular blockers during life-support withdrawal or to restore neuromuscular function before ceasing mechanical ventilation persists. As nurses, we must focus our efforts on delivering dynamic care that reflects both evidence-based and ethics-based practices.

Selected references
Campbell ML, Bizek KS, Thill M. Patient responses during rapid terminal weaning from mechanical ventilation: a prospective study. Crit Care Med. 1999;27(1):73-77.

Domino KB, Posner KL, Caplan RA, Cheney FW. Awareness during anesthesia: a closed claims analysis. Anesthesiology. 1999;90(4):1053-1061.

Sebel PS, Bowdle TA, Gonheim MM, et al. The incidence of awareness during anesthesia: a multicenter United States study. Anesth Analg. 2004;99(33):833-839.

Truog RD, Burns JP, Mitchell C, Johnson J, Robinson W. Pharmacological paralysis and withdrawal of mechanical ventilation at the end of life. N Engl J Med. 2000;342(7):508-511.

Truog RD, Cist AF, Brackett SE, et al. Recommendations for end-of-life care in the intensive care unit: the Ethics Committee of the Society of Critical Care Medicine. Crit Care Med. 2001;29(12):2332-2348.

For a complete list of selected references, visit www.AmericanNurseToday.com.

Carrie Gabrys, RN, CPNP, Andrea Kline RN, CPNP-AC, FCCM, and Elizabeth Preze, RN, CPNP, PC/AC, are Pediatric Nurse Practitioners in the Intensive Care Unit of Children’s Memorial Hospital in Chicago, Illinois.

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