B55-08 Sedation, Opioid Use, and Time to Death in ICU Comfort Care Extubations: Comparison of Donation After Cardiac Death (DCD) and Non-DCD Patients

Rationale Comfort care extubation is common practice for patients transitioning from life-sustaining mechanical ventilation, emphasizing relief of suffering through opioids and benzodiazepines. While these medications may secondarily shorten survival, their rationale for use is to provide comfort. In Donation after Cardiac Death (DCD), the presence of organ procurement teams and time-sensitive logistics may influence end-of-life care delivery. DCD protocols differ from standard care in location, participation of non-clinical teams, and procedural timing, all of which may influence medication administration. We hypothesized that DCD patients receive higher cumulative doses of opioids and benzodiazepines and experience shorter time to death compared with non-DCD patients. Methods We conducted a 3-year retrospective cohort study of adult ICU decedents who underwent comfort care extubation at a tertiary/quaternary medical center. Patients were categorized by DCD candidate status. Data abstracted included demographics, history, sedative and analgesic dosing, ventilator settings, and time from extubation to death. Primary endpoints were cumulative opioid and benzodiazepine dose and time to death. Opioids were converted to morphine milligram equivalents (MME). Group comparisons used Fisher’s exact test, and differences in mean MME were assessed by permutation testing. Results Among 253 decedents (8 DCD, 245 non-DCD), DCD patients were younger (87.5% were younger than 55 yrs vs 22.4% of non-DCD, p < 0.01). Cumulative opioid dosing within 48 hours before extubation did not differ. However, in the 4 hours before and after extubation, DCD patients more often received greater than 100 MME (62.5% vs 20.8% of non-DCD) and non-DCD patients more often received less than 25 MME (36.7% vs 0% in DCD, p = 0.01). Benzodiazepine dosing did not differ between the two groups. Time from extubation to death was similar (p = 0.99). Half of DCD patients had positive toxicology for amphetamine, cocaine, or fentanyl. Conclusions In this cohort, DCD patients were younger and received higher cumulative doses of opioids than non-DCD patients. The greater opioid usage might be explained by several factors: younger age with greater metabolism and higher tolerance in the setting of positive drug screens. Median time from extubation to death did not differ between groups. These findings suggest that while time-sensitive donation protocols may influence sedation and analgesia practices, they do not appear to hasten death. Multi-center studies would be useful to determine whether the unique, time-sensitive protocols applied to DCD patients influence comfort care delivery, to ensure consistent, equitable, and ethical end-of-life care. This abstract is funded by: none