Symptom control during palliative extubation — FFICM MCQ

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ModerateEthics and End-of-lifeSymptom control during palliative extubationFFICM

A 74-year-old man with irreversible multiorgan failure is to have ventilation withdrawn after a best interests decision. He is tachypnoeic and grimacing when sedation is reduced. His family are present and ask whether he will feel breathless. Renal failure is severe. What is the most appropriate management?

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Correct answer: D — Anticipate distress and titrate opioid and sedative medication to symptoms

The correct answer is D, anticipate distress and titrate opioid and sedative medication to symptoms. When ventilatory support is withdrawn in irreversible multiorgan failure, breathlessness, tachypnoea and grimacing on reducing sedation are expected distress signs that must be pre-empted, not just reacted to. NICE guidance on care of the dying adult recommends anticipatory prescribing of opioids and sedatives, individualised and titrated to observed response rather than fixed protocols; this matters here because severe renal failure impairs clearance of active opioid metabolites (for example morphine-6-glucuronide), risking unpredictable accumulation, so smaller incremental doses with close monitoring are safer than fixed regimens. The explicit aim is comfort and relief of suffering, and the family can be reassured symptom control, not hastening death, is the goal. Why the other options are wrong: A, Stop analgesia to avoid hastening death: withholding analgesia leaves breathlessness and pain untreated; the doctrine of double effect permits proportionate symptom relief even if it may incidentally shorten life, so analgesia must continue. B, Give a fixed large bolus to ensure unconsciousness: a fixed large dose ignores individual titration and risks rapid cardiorespiratory depression, particularly with renal impairment slowing clearance, and could be seen as deliberately hastening death rather than relieving symptoms. C, Paralyse him without sedation: neuromuscular blockade masks visible distress without treating it, so the patient could feel breathless yet be unable to show it; this is ethically unacceptable at end of life. D, Extubate first and treat symptoms later: symptom control and anticipatory medication must be in place before and during extubation, not arranged reactively after distress appears. Key point: In palliative extubation, opioids and sedatives are prescribed anticipatorily and titrated to the patient's observed symptoms, with extra caution on dosing in renal failure, ensuring comfort without deliberately hastening death.

Reference: NICE Guideline NG31, Care of dying adults in the last days of life (2015, updated 2017), section on anticipatory prescribing and symptom management; https://www.nice.org.uk/guidance/ng31