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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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The Procedure of Mechanical Ventilator Withdrawal

  1. 1. THE PROCEDURE OF VENTILATOR WITHDRAWAL KYLE P. EDMONDS, MD DORIS A. HOWELL PALLIATIVE CARE CONSULT SERVICE UC SAN DIEGO HEALTH SYSTEM
  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

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