The Procedure of Mechanical Ventilator Withdrawal


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Frames withdrawal of mechanical ventilation as a procedure requiring preparation and team-based care. Begins with an overview of ethical & legal implications and then moves step-by-step through withdrawal of ventilatory support.

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  • There is no ethical differentiation between withholding and withdrawing therapy even though the two may feel quite differentThe principle of autonomy affords patients (and their surrogates, when appropriate) the right to refuse medical care even if that decision may, in the opinion of the treating team, hasten their death. It is the duty of the team to balance risk and harm with respect to medical interventions Avoid interventions that will bring undue morbidity and mortality. WE SHOULD BE IN SUPPORT OF PATIENT/FAMILY DECISIONS, AND LEAD, BUT NOT FORCEIt is ethical to withhold or withdraw mechanical ventilation for the patient who lacks decision-making capacity after discussion with the appropriate proxy.AMA Code of Medical Ethics. Opinion 2.20: Withholding or withdrawing life-sustaining treatment. American Medical Association. Updated 1996.
  • Informed consent is a fundamental ethical principle that underlies contemporary medical carePatients deserve a clear, complete understand­ing of all therapies that are being proposed for themSome will want to know all the details and others will prefer not to know anythingBe prepared to describe in simple, neutral terms the aspects of artificial nutrition and hydration in a manner that conforms to the principles of informed consentThe problem the treatment would addressWhat is involved in the treatment or procedureWhat is likely to happen if the patient decides not to have the treatmentThe benefits of the treatmentThe burden created by the treatmentImage credit:
  • All states in the United States have statutes covering issues related to withholding or withdrawing life-sustaining treatmentsIt is a duty of the clinician to be aware of relevant institutional policy, law and statute for their area of practice.
  • Physician will often take the lead in:Initiating discussions about life-sustaining treatmentFacilitating deliberationProviding recommendations and opinions where appropriateEVERYMEMBER OF THE TEAM PLAYS A ROLE IN….Educate patients & familiesFacilitate deliberationImplement the treatment planReassess progressEnsure good documentation and communication of the plan and the patient’s wishesConsequently, it is critical that all members of the team have the knowledge and skills necessary for discussions, negotiations, and implementation of decisions related to these therapiesImage credit:
  • There are several common concerns that impact decisions about life-sustaining treatments in general and withdrawal of hydration and nutrition in particularAre clinicians legally required to provide all life-sustaining measures possible?NoClinicians are required to provide care that will accomplish treatment goals within the bounds of accepted medical practiceNo clinician is required to provide care that is not medically appropriateConversely, even when a treatment might prolong life, eg, intravenous antibiotics for pneumonia, patients have a right to refuse, and the clinician has an obligation not to provide or coerceIs withdrawal or withholding of artificial hydration and nutrition euthanasia?NoBy definition, euthanasia is a physician-performed intervention with the goal of ending the patient’s lifeAfter decades of discussion in society, there is strong general consensus that withdrawal or withholding of ventilatory support is a decision/action that allows the illness to progress on its natural courseIt is not a decision/action actively to seek death and end lifeCan the treatment of symptoms associated with withdrawal of hydration and nutrition constitute euthanasia? NoThe intent of the clinician and the means used to accomplish the intent are importantOpioids for pain, sedatives for restlessness, and other treatments to control symptoms are not euthanasia when accepted dosing guidelines are usedSymptom treatment alleviates symptoms; it does not intentionally cause death
  • The purpose of this section is to describe an approach (based on the literature and expert opinion) that can guide the physician through such an encounter. If you are uncertain, seek the assistance of experienced colleagues and other health care professionals to help in the process.Assess whether removal from the ventilator is appropriate and desired First, discuss the overall goals in light of the patient’s medi­cal condition;Then, consider the role that artificial ventilation might play in achieving those goals.Image credit:
  • Immediate:This is the preferred approach to relieve discomfort if the patient is conscious;the volume of secretions is low;the airway is unlikely to be compromised after extubation. Weaning:This is the preferred approach if there is concern for acute airway compromise following extubationIf ET tube is to stay in place, a Briggs T piece may be used in place of the ventilatorAlternatively, patients may ultimately be extubated
  • Preparation is keyTeamFamilyPatientMedicationsDyspneaThe subjective sense of not getting enough air.Opioids the most effective medication for relieving the sense of breathlessness;work through both central and peripheral mechanisms of action. May not change rate or pattern of breathing;Monitor response through patient comfort.Titrate the dose with the intent to achieve comfort;increasing doses beyond the levels needed to achieve comfort or se­dation has the potential to hasten death.OxygenMay correct hypoxia without improving dyspneaAnxietyBenzodiazepines such as midazolam, lorazepam, and others are the most effective anx­iolytic drugs in this setting.Usually used in combination with opioids for severe breathlessness.Opioids only have transient and unreliable anxiolytic effects in opioid-naive patients and should not be used for this purpose. Image credit:
  • If the patient is awake and aware, they will need to be involved in the family preparation as described on the next slideSpiritual needsSpecific rituals that need to be prepared forTimelines after death that the team needs to prepare forIs a visit with a member of their spiritual community desired/requiredAre all those loved ones present who the patient would want to be involvedImage credit:
  • Never make assumptions about what the family understands. Describe the procedure in clear, simple terms and answer any questions. Assure them that the patient’s comfort is of primary concern. Explain that breathlessness may occur, but that it can be managed. Con­firm that you will have medication available to manage any discomfort. Ensure they know that you may need to put the patient to sleep. Clarify whether the family would like to be at the bedside for removal of the ET tube. Some may and others may not want to be there.Physical findingsAssure them that involuntary moving or gasping does not reflect suffering if the patient is properly sedated Describe possible breathing patternsNo breathing at allInitial reflexive gasping breath once ET tube removedDescribe agonal pattern without using the word “agonal” as some may relate this to “agony”Image credit:
  • It is important for the physician to prepare the family for the range of outcomes that might occur.rapid death within minutes (typically patients with sepsis on maximal blood pressure support);death within hours to days;Stabilization of cardiopulmonary function leading to a different set of care plans, including potential hospital discharge (as many as 10% of patients in some studies). If the latter possibility is realistic, future management plans should be discussed prior to ventilator removal, since some families may desire to resume certain treatments, notably artificial hydration/nutrition.Explain how the family can show love and supporttouch, wiping of the patient’s forehead, holding a handtalking to him or her Sharing stories at the bedsideInvolving the family in this way can help take their eyes off the medical preparations and interventions that will be happening.Image credit:
  • Determine if there is an institutional policy or protocol that should guide you as you move forward. Determining the team rolesBest done outside the roomShould be clear prior to proceedingWho needs to be present and who does not (does the team outnumber the family?)Multidisciplinary support is crucial to achieving a smooth withdrawal of ventilatory supportNursing preparations will be intenseEnsure that he or she has a clear picture of what needs to be done and what needs to be at bedsideDesignate someone to assist with running for additional medications/supplies during the procedurePharmacy can assist with dosing recommendationsChaplaincy or social work may have developed a therapeutic relationship with the patient and/or family In low resource areas, the entire procedure can be completed by a single clinician from the teamImage credit:
  • Discontinue paralytics.Administer an IV bolus dose begin an IV continuous infusion (sample dosing on the next slide). Do not rely on subcutaneous or enteral drug administration as these take longer to work. For children, obtain dosing advice from a pharmacist or pediatric intensivist.Titrate drugs to control labored respirations and achieve the desired state of sedation prior to extubation.Testing the eyelid reflex is a common method of quickly assessing level of consciousness.Have additional medication drawn up and ready to administer at the bedside if needed.After ventilator withdrawal: If distress ensues immediate symptom control is needed. Use additional medication (e.g. morphine 5-10 mg IV push q 10 min, and/or midazolam, 2-4 mg IV push q 10 min, until distress is relieved). Adjust infusion rates to maintain relief.Specific dosages are less important than the goal of symptom relief. A goal should be to keep the respiratory rate < 30 and eliminate grimacing and agitation.Image credit:
  • Many institutions have policy and clinical guidelines about the use of opioids and sedatives in these circumstances. The following regimens are commonly used; all require a bolus dose followed by a continuous infusion.Dose ranges are approximations and depend in part on patients’ prior exposure to opioids and benzodiazepines.Clinicians should use clinical judgment when deciding on what specific drugs and doses to use. Clinicians unfamiliar with the use of these agents in the setting of ventilator withdrawal are urged to consult with an anesthesiologist, critical care specialist, or pain/palliative specialist prior to use.--Regimen B: Pentobarbital (Adult doses)Awake patients who can be expected to have respiratory distress.Bolus: 1-2 mg/kg (at rate of 50 mg/min)Infusion: 1-2 mg/kg/hrRegimen C: Propofol (Adult doses)Awake patients who can be expected to have respiratory distress.Bolus: 20-50 mgInfusion: 10-100 mg/hr
  • Given this, I would like you to think about starting morphine drips. Often times, we will increase drips, we will titrate them up, when people have symptoms out of control.Can anyone think of a problem with this, knowing what we now know??When will that drip reach steady state…reach its maximum effect?
  • Silence alarmsEnsure that all monitors and alarms are turned off Ensure that respiratory therapy or nursing staff is assigned to override alarms that cannot be turned off.Physically prepare the patientRemove restraints and unnecessary medical paraphernalia.Turn off blood pressure support and paralytic medicationsDiscontinue other life-sustaining treatments (e.g. artificial nutrition/hydration, antibiotics, dialysis).Maintain intravenous access for administration of sedating medications.Set the physical spaceOnly crucial team members should be present, minimize medical presence as much as appropriate.Clear a space for family access to the bedside. Invite all those family who want to be present for ET removal into the room. If the patient is an infant or young child, offer to have the parent hold the child.Image credit:
  • Establish adequate symptom control prior to extubation.Bolus doses prior to or at the time of extubation may be appropriate.Have syringes of an additional medication prepared at the bedside to use in case of dyspnea or other symptoms.Once you are sure the patient is comfortable, set the FiO 2 to 21% (room air)observe for signs of respiratory distress; adjust medication as needed to relieve patient’s apparent or stated distress before proceeding further.If the patient appears comfortable, prepare to remove the endotracheal tube.A nurse or respiratory therapist should be stationed at the opposite side of the bed with a washcloth and oral suction catheter.When ready to proceed, deflate the endotracheal (ET) tube cuff. If possible, someone should be assigned to silence, turn off the ventilator, and move it out of the way. Once the cuff is deflated, remove the ET tube under a clean towel which collects most of the secretions and keep the ET tube covered with the towel. If oropharyngeal secretions are excessive, suction them away.Image credit:
  • Consider the physical spaceLower the bedrails if appropriateMaintain easy access to the patient’s head and lines for bolus medications and suctionInvite remaining family to join at the bedsidethose present to surround the bedThe family and the nurse should have tissues for extra secretions, and for tears. The family should be encouraged to hold the patient's hand and provide assurances to their loved one.Be prepared to spend additional time with the family discussing questions concerns.Image credit:
  • After the patient diesThere is no need to rush anyone. Encourage the family to spend as much time at the bedside as they require. Provide acute grief support.Check in with the team and debriefthey may be grieving as well;this is especially true for patients who may have been in the ICU for a long period of time. BereavementOnce they are ready to leave, provide the family with the physician’s name and phone number, if they have any questions. Offer follow-up bereavement support.Send a bereavement card to family members .Image credit:
  • Non-invasive positive pressure ventilation (CPAP, BiPAP)Should be treated the same as the abovePatients may be more able to participate in the process and should be included in preparation if possibleChildren As mentioned above, the medical procedure of removing ventilatory support from children is the same as adults exceptDosing should be reviewed with pharmacyIt may be advisable to facilitate an Ethics Committee consult Children may be more likely to survive for a longer period of time following extubationPlan for whether the patient will stay where they are or be moved after a certain timeConsider working with local inpatient hospice facilities as availableFacilitate keepsakes for familiesHand printsLocks of hairEmpower the family to think of other options that are meaningful to themImage credit:
  • The Procedure of Mechanical Ventilator Withdrawal

    2. 2. SUMMARY The withdrawal of mechanical ventilation is a procedure that requires considerable preparation from all of those involved.
    3. 3. ETHICAL PRINCIPLES  Withdrawing is the same as withholding  Patient autonomy allows for refusal of care  Clinicians help balance benefit and harm  All patients are entitled to informed consent
    4. 4. INFORMED CONSENT  Ethical & legal requirement  As for any procedure
    5. 5. LEGAL PRINCIPLES  US case law upholds mechanical ventilation as a medical intervention that can be refused  Legal precedent will vary country-to-country
    6. 6. ROLE OF THE TEAM  Help the patient & family • Elucidate their values • Understand the facts • Dispel misconceptions  Establish goals of care  Facilitate decisions  Reassess regularly
    7. 7. COMMON CONCERNS  Am I legally required to ‘do everything’?  Is this euthanasia?  Am I killing the patient when I withhold or withdraw ventilatory support?
    8. 8. PROCEDURE OVERVIEW  Challenging  Ask for assistance  Assess appropriateness of request  Role in achieving goals of care
    9. 9. OPTIONS  Immediate • Remove the endotracheal tube • Give humidified air or oxygen  Weaning • Rate, PEEP, oxygen levels decreased first • Over 30–60+ minutes
    10. 10. PRINCIPLES  Treat like any procedure  Anticipate & preparation key  Prevent symptoms  Titrate rapidly to comfort  Be present to assess, reevaluate
    11. 11. PATIENT PREPARATION  Will differ if patient aware  Spiritual needs  Loved ones present
    12. 12. FAMILY PREPARATION  Describe the procedure • Reassure comfort is primary • Medications available • Patient may sleep  Physical Findings • Involuntary movements • Breathing patterns
    13. 13. FAMILY PREPARATION  Describe Uncertainty  minutes  hours to days  stabilization  Bedside love & support  touch, holding a hand  talking to patient  Sharing stories
    14. 14. TEAM PREPARATION  Determine the team roles • Chaplaincy • Nursing • Pharmacy • Provider Teams • Respiratory Therapy • Social Work
    15. 15. MEDICAL PREPARATION  Determine appropriate degree of consciousness  Titrate to consciousness & comfort
    16. 16. MEDICATION DOSING  Example: Morphine plus Midazolam (Adult doses) • Comatose patients and/or patients with little prior exposure to these drugs • Bolus: Morphine 2-10 mg; Midazolam 1-2 mg • Infusion • Continue present infusion rate • Use bolus need to guide rate
    17. 17. Time to Drip Steady State Plasma Concentration Change GTT Pain Control 100% 97% 93.75% 87.5% 75% 50% 0 4 8 12 16 20 24 Time ( hours )
    18. 18. PROTOCOL  Silence alarms  Prepare the patient  Turn off monitors  Prepare the physical space
    19. 19. PROTOCOL  Ensure symptom control  Have medications IN HAND  Set FiO2 21%  Adjust medications  Remove the ET tube
    20. 20. PROTOCOL  Monitor the physical space  Invite family to bedside  Washcloth, oral suction catheter, facial tissues  Reassess frequently
    21. 21. PROTOCOL  After death • Check in • Allow time  Offer bereavement support
    22. 22. SPECIAL CONSIDERATIONS  Noninvasive ventilatory support  Children
    23. 23. SUMMARY The withdrawal of mechanical ventilation is a procedure that requires considerable preparation from all of those involved.
    24. 24. REFERENCES  Marr, Lisa, and David E. Weissman. "Withdrawal of Ventilatory Support from the Dying Adult Patient." Supportive Oncology 23.2 (2004): 283-88. PMID: 15328827  Munson, D. "Withdrawal of Mechanical Ventilation in Pediatric and Neonatal Intensive Care Units." Pediatric Clinics of North America 54.5 (2007): 773-85. PMID: 17933622  Sine, David, Lizabeth Sumner, Delaney Gracy, and Charles F. Von Gunten. "Pediatric Extubation: ‘Pulling the Tube’" Journal of Palliative Medicine 4.4 (2001): 519-24. PMID: 11798487  Truog, Robert D., Margaret L. Campbell, J. Randall Curtis, Curtis E. Haas, John M. Luce, Gordon D. Rubenfeld, Cynda Hylton Rushton, and David C. Kaufman. "Recommendations for End-of-life Care in the Intensive Care Unit: A Consensus Statement by the American Academy of Critical Care Medicine." Critical Care Medicine 36.3 (2008): 953-63. PMID: 18431285  Von Gunten CF, Weissman DE. Ventilator Withdrawal Protocol, 2nd Edition. Fast Facts and Concepts. July 2005; 33/34/25