Liverpool Care Pathway - "No Midazolam"

The terrors of Trelkovsky...
Roman Polansky's dark imaginings are realised in his screenplay but the truth is darker and more terrible than the fiction.


Colin Tidy advises on Prescribing in Palliative Care at Patient.co.uk

   Excessive respiratory secretions ('death rattle')

• This is particularly distressing for relatives.
• If present, this may be reduced by use of hyoscine hydrobromide or glycopyrronium. Particular attention should be given to mouth care, as this will cause an extremely dry mouth..

This is "particularly distressing for relatives..."

Prescribing, then, is cosmetic, for the benefit of the relative rather than the patient. What is paramount is the perception that the passing of the loved one has been peaceful, for it is "how people die [that] remains in the memory of those who live on".

So, what of the patient...?

Colin Tidy continues -

Restlessness and confusion:

• Haloperidol (little sedative effect).
• Levomepromazine.
• Midazolam (useful where a patient is restless or fitting).

Midazolam is mentioned for its compatability to be used in a syringe driver, as PRN medication, for anticipatory prescribing and sedation.

This is frightening. This is quite terrifying.

Midazolam actually induces a condition of paralysis; the patient appears calm and sedated but is, in reality, alert and unable to move. This is a personal account of its use and effects.

This is Midazolam  -

The whole premis of Versed [Midazolam] being "relaxing" is flawed. How can it be relaxing when the patient is aware and awake?No Midazolam 

Upon injection of Versed [Midazolam] , which I am pointing out is an INCAPACITATING DRUG, the first thing I noticed was an inability to speak. In my head, everything seemed normal, except that when I tried to talk, gibberish came out. I was very puzzled. Had to think about THAT little item. Unfortunately as I was trying to figure out why I couldn't get the words to form from my mouth, the nurse was busily injecting more poison into my body.

The next thing I noticed was that I was very obedient. I had a desire to obey them and I did. At least my body did. There was a peculiar disconnect from my brain to my body. I could not stop myself from obeying their every command. Trust me, this is not comforting at all. In the TRAPPED part of me, my soul if you will, I was frustrated, infuriated, horrified, aghast, etc. that my body was obeying THEM and was completely beyond my control. I have never felt so helpless and humiliated in my life. My blood pressure and heart rate shot up.
My body continued to obey them as they prepared to do what my surgeon wanted. I couldn't believe it! I still can hardly believe it. I was totally trapped in a part of my brain, watching, listening and enduring. Bad, bad, BAD experience. No Midazolam

This account is reminiscent of the experience of Trekovsky, the leading character in the film, The Tenant. Both starring and directed by Roman Polansky, the film provides a curious psychological twist.

Trelkovsky (Roman Polanski) rents an apartment in Paris. The previous tenant, Simone Choule, has attempted suicide by throwing herself out the window.Trelkovsky visits her in hospital but finds her entirely swathed in bandages. The immobile Simone appears to attempt to speak but is unable to do so.

The end of the film provides the psychological twist. Trelkovsky is bandaged up in the same fashion as Simone Choule in the same hospital bed. The camera views the ward through his eyes, but we see his own visit to Simone.

The impossible horror of the situation strikes Trelkovsky as he attempts to communicate with his past self - but cannot.

This is Midazolam according to Medscape -

midazolam (Rx) - Versed

Preoperative Sedation/Anxiolysis With Anterograde Amnesia

IM

• 70-80 mcg/kg (dose range ~5 mg) 30-60 minutes before surgery (reduce 50% for chronically ill or geriatric patients) 

IV

• Initial: Usually 0.5-1 mg given over 2 minutes (not to exceed 2.5 mg/dose); wait 2-3 minutes to evaluate sedative effect after each dose adjustment; total dose >5 mg usually not necessary to reach desired sedation; use 30% less midazolam if patient premedicated with narcotics or other CNS depressants
• Debilitated or chronically ill patients: 1.5 mg IV initially; may repeat with 1 mg/dose IV q2-3 min PRN; not to exceed cumulative dose of 3.5 mg; peak effect may be delayed in elderly, so increments should be smaller and rate of injection slower
• Maintenance: 25% of initial effective dose PRN by slow titration; reduce 30% if premedicated with opiate (50% in elderly/chronically ill)

Anesthesia

Induction

• <55 years without premedication: 300-350 mcg/kg IV injection over 20-30 seconds; wait 2-3 minutes to evaluate sedative effect after each dose adjustment; may use increments of 25% of initial dose PRN to complete induction; may use up to 0.6 mg/kg total dose in resistant cases, but such dosing may prolong recovery 
• >55 years without premedication and with no systemic disease, in a patient who is not weak: 300 mcg/kg over 20-30 seconds initially; wait 2-3 minutes to evaluate sedative effect after each dose adjustment
• >55 years without premedication but presence of systemic disease or weak patient: 200-250 mcg/kg over 20-30 seconds usually enough; 0.15 mg/kg enough in some cases; wait 2-3 minutes to evaluate sedative effect after each dose adjustment
• >55 years with premedication: 150-350 mcg/kg IV injection over 20-30 seconds; wait 2-3 minutes to evaluate sedative effect after each dose adjustment; a dose of 250 mcg/kg usually enough to achieve desired effect

Maintenance

• May administer increments of 25% of induction dose PRN when there are signs that anesthetic effects are lightening

Geriatric Dosing

Preoperative sedation/anxiolysis with anterograde amnesia

• IM: 1-3 mg (~35-40 mcg/kg) 30-60 minutes before surgery; some elderly patients may respond to as little as 1 mg; onset is 15 minutes (peaking at 30-60 min)
• IV (>60 years): 1.5 mg initially; may repeat with 1 mg/dose q2-3min PRN; not to exceed cumulative dose of 3.5 mg; peak effect may be delayed in elderly, so increments should be smaller and rate of injection slower
• IV maintenance: 10-15% of initial effective dose PRN by slow titration

Dosing considerations

• Anesthesia: Typical adult induction and maintenance doses may need to be decreased in some elderly patients by 20-50%, because the elderly overall are more susceptible to CNS depressants than is the general population

The use of Midazolam in the LCP is perceived to be beneficial, but must be a terrifying experience  for the patient.

Part of the CQUIN framework is the PROM. PROMs "are a means of capturing patient perspectives on the effectiveness of their care". The only problem with PROMS in regard to the LCP, of course, is that the patient is (more than likely) dead.