Module 39 · Skills & practice

Ethics, communication and palliative care

NewPhase 2

Ethics, communication and palliative care in the ICU: breaking bad news (SPIKES), family meetings and shared decisions, Indian law on withholding and withdrawing treatment (Common Cause 2018/2023), palliative symptom care and compassionate extubation, the organ donation request, and documentation and medico-legal practice.

6 topics

Drugs in this module

Doses written for this module's context. The same drug may read differently in another module.

Morphine

Opioid analgesic

Indications
Pain and breathlessness at the end of life
Adult dose
Opioid-naive: 1-2 mg IV or 2.5-5 mg SC as needed (every 1-2 h); infusion 0.5-2 mg/h IV/SC titrated to comfort. Patients already on opioids: continue and increase by 25-50% for uncontrolled symptoms.
Preparation (India)
10 mg/mL and 15 mg/mL ampoules (NDPS licensing required; availability restricted in some hospitals).
Renal / hepatic
Active metabolites accumulate in AKI/CKD - use smaller doses, longer intervals or fentanyl.
Cautions
Titrate to symptoms, not to a time of death; document intent (comfort).

Midazolam

Benzodiazepine

Indications
Anxiety, distress, agitation and palliative sedation at the end of life; seizures
Adult dose
1-2 mg IV or 2.5-5 mg SC as needed; infusion 0.5-2 mg/h IV/SC titrated to comfort.
Preparation (India)
1 mg/mL and 5 mg/mL ampoules.
Renal / hepatic
Accumulates in renal and hepatic failure.
Cautions
Combine with opioid for distressing breathlessness only when anxiety is prominent.

Glycopyrronium (glycopyrrolate)

Antimuscarinic (does not cross blood-brain barrier)

Indications
Noisy respiratory secretions ('death rattle')
Adult dose
200 mcg SC/IV every 4-6 h as needed (maximum about 1.2 mg/24 h).
Preparation (India)
0.2 mg/mL ampoules.
Cautions
Dry mouth, urinary retention; best given early; reassure families that the noise is rarely distressing to the patient.

Hyoscine butylbromide

Antimuscarinic

Indications
Noisy respiratory secretions; colic
Adult dose
20 mg SC/IV every 4 h as needed (maximum 120 mg/24 h).
Preparation (India)
20 mg/mL ampoules (widely available in India).
Cautions
Tachycardia, dry mouth, urinary retention.

Module references (13)

  1. 1

    Ministry of Health and Family Welfare, Government of India. Transplantation of Human Organs and Tissues Act 1994 (amended 2011) and Transplantation of Human Organs and Tissues Rules, 2014. NOTTO.

  2. 2

    Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES - a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000;5:302-11.

  3. 3

    Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007;356:469-78.

  4. 4

    Davidson JE, Aslakson RA, Long AC, et al. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med 2017;45:103-28.

  5. 5

    Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med 2015;191:1318-30.

  6. 6

    Chawla R, Kapadia F, Rajagopalan S, Amin P, et al. Guidelines for end-of-life and palliative care in Indian intensive care units: ISCCM consensus ethical position statement. Indian J Crit Care Med 2012;16:166-81.

  7. 7

    Kapadia F, Rajagopalan S. The ISCCM/IAPC position statement: ending the Sisyphean struggle to practice ethical end-of-life care in India. Indian J Crit Care Med 2024;28(3):189-90.

  8. 8

    Supreme Court of India. Common Cause (A Regd. Society) v. Union of India and Another, Writ Petition (Civil) No. 215 of 2005, judgment of 9 March 2018, (2018) 5 SCC 1.

  9. 9

    Supreme Court of India. Common Cause (A Regd. Society) v. Union of India, Miscellaneous Application No. 1699 of 2019 in WP (C) 215 of 2005, order of 24 January 2023, [2023] 1 SCR 1137.

  10. 10

    Truog RD, Campbell ML, Curtis JR, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med 2008;36:953-63.

  11. 11

    Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med 2014;370:2506-14.

  12. 12

    National Institute for Health and Care Excellence. Care of dying adults in the last days of life (NG31). London: NICE; 2015.

  13. 13

    Medical Council of India. Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 (as amended). Reproduced in Indian Journal of Medical Ethics.