Michael J. Burran, MD
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Burran MJ. Reflections on the Doctor's Anguish. Ann Intern Med. 1993;118:78-80. doi: 10.7326/0003-4819-118-1-199301010-00027
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Published: Ann Intern Med. 1993;118(1):78-80.
TO THE EDITOR:
Drs. Edwards and Tolle  describe the emotional and ethical issues in withdrawing mechanical ventilation. They emphasize the conflict between the value of sedation to patient comfort and the medical concern about the decrease in respiratory drive and possible hastening of death.
We have found a variation of the “terminal weaning” described by Grenvik  to be valuable. Ventilatory support, withdrawn gradually over a few hours using decreasing levels of mechanical ventilation or pressure support, plus small doses of intermediate-duration narcotics and benzodiazepines, allow minimal sedation and respiratory depression consistent with patient comfort. In the fully conscious patient, patient-controlled analgesia devices allow the patient to initially balance sedation and relief of dyspnea. However, unlike Dr. Grenvik's procedure, we do not routinely check arterial blood gases, because the sole goal of our therapy is patient comfort in dying. In our experience, several patients have been able to achieve conscious extubation, allowing them valuable time in the company of their families.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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