Neuro Muscular Blockade and End of Life Care

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The question of how to manage patients receiving neuromuscular blocking agents at end-of-life care remains controversial. In most cases, neuromuscular blocking agents should be discontinued before withdrawal of life support to allow optimal pain control and sedation. If prolonged paralysis is recognized as an iatrogenic complication of the patient’s treatment, then insisting that this complication be resolved before acceding to the family’s request to withdraw life support could be seen as placing the concerns of the care team above those of the patient and family. The following recommendations are therefore made: ^{1 2 3}

1. Neuromuscular blocking agents should never be initiated at the time of withdrawal of life support, including mechanical ventilation or initiation of comfort care.
2. In patients who are already receiving neuromuscular blocking agents for therapeutic reasons, neuromuscular function should ideally be restored before withdrawal of life support, to allow optimal pain control and sedation. Ensure that the effects have been reversed (i.e. confirm Train of Four has returned to pre-paralytic agent administration level or respiratory effort has returned) prior to ventilator withdrawal.
3. The only exception to this rule should be when death is expected to be both rapid and certain after removal of the ventilator, and when the burdens to the patient and family of waiting for the neuromuscular blockade to diminish to a reversible level exceed the benefits of allowing better assessment of the patient’s comfort and the possibility of interaction with loved ones. In these cases, an Ethics Committee and/or Palliative Care consult can be considered.

Assuming that skilled and experienced clinicians are available and that the patient’s family has been informed and agrees with this assessment, the withdrawal of life support can ethically occur in the presence of pharmacologic neuromuscular blockade. Clinical skill and judgment should guide the administration of sedatives and analgesics to ensure the comfort of the dying patient.

4. When restoring neuromuscular function would impose an unacceptable delay on the withdrawal of life support, withdrawal may proceed, with particular attention given to ensuring the comfort of the patient through the dying process, recognizing that signs of discomfort will be difficult to detect.