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Table 1 National guidelines for the Staged Escalation of pharmacologic management of distress from the withdrawal of nutrition and hydration in prolonged disorders of consciousness a

From: Nonconsensual withdrawal of nutrition and hydration in prolonged disorders of consciousness: authoritarianism and trustworthiness in medicine

Stage 1: Continuous IV infusion of benzodiazepines and opioids Medications are best loaded in separate syringe drivers so that they can be varied independently until the optimum regimen is established. Set up 2 IV syringe drivers and commence IV infusion with midazolam (10 mg/24 h) and morphine (10 mg/24 h). Prescribe bolus IV doses of each drug to be given by the syringe pump. Adjust the infusion dose according to the frequency of bolus doses required (midazolam, up to 10–20 mg/h; morphine, 10 mg/h). However, if no effect is seen from bolus doses, the patient is receiving the maximum benefit from these drugs. Progress to stage 2.
Stage 2: Continuous IV infusion of neuroleptics Continue the current doses of morphine and midazolam in 1 IV syringe driver. Set up a second syringe driver with levomepromazine (50 mg/24 h). Prescribe bolus IV doses of levomepromazine (12.5-25 mg). However, if no effect is seen from bolus doses, progress to stage 3.
Stage 3: Continuous IV infusion of barbiturates Continue morphine and midazolam at current dose in first continuous IV infusion. Stop levomepromazine. Replace with phenobarbitone (600 mg/d) in a second continuous IV infusion. Prescribe phenobarbitone (100–200 mg) IV bolus doses. If not responding to bolus doses, proceed to stage 4.
Stage 4: General (self-ventilating) anesthesia In very rare cases, severe physiologic distress with terminal agitation may require self-ventilating IV anaesthesia. This should be administered with the support of ITU-trained staff under the supervision of a consultant anaesthetist.
  1. Abbreviations: ITU intensive therapy unit, IV intravenous.
  2. Reproduced from: Royal College of Physicians. Prolonged disorders of consciousness: National clinical guidelines. London: RCP, 2013 (p. 84) [1]. Copyright © 2013 Royal College of Physicians. Reproduced with permission.
  3. aThe table illustrates the staged escalation of benzodiazepines, opioids, neuroleptics, and general anesthesia in the end-of-life care pathway after the withdrawal of nutrition and hydration in prolonged disorders of consciousness.
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