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There are three distinct methods of ventilator withdrawal:
Terminal extubation has been criticized because it can lead to marked respiratory struggling and significant distress that is profoundly disturbing to patients, family members, and health care professionals (Gilligan and Raffin, 1995; Strother, 1991). Furthermore, distress from airway compromise cannot be easily reduced with analgesia or sedation (Carlson et al., 1996). The only clear circumstance in which terminal extubation is an appropriate withdrawal method is for the patient who is brain-dead and incapable of experiencing distress from airway compromise.
Terminal weaning affords precise titration of medications and careful adjustment of the process itself to ensure patient comfort. The process can be accomplished rapidly, over minutes to hours, or in a more protracted fashion of several hours, depending on the patient's circumstances. Preliminary results from a prospective study of patient responses during ventilator withdrawal suggest that an immediate cessation of ventilation by placement on a t-bar can be accomplished without patient distress in the face of severe neurological insults (e.g., global anoxic encephalopathy) in which the patient has only brain-stem activity. A rapid terminal wean afforded comfort for patients with some cortical activity and the possibility of experiencing distress (Campbell, 1998).
The decision to extubate could be handled as a secondary decision following the withdrawal. Airway problems can develop after extubation and are potential sources of distress to patients, families, and caregivers. One investigation reported no distress in patients terminally extubated; however, 28 percent of patients in that sample had gasping/labored respirations that may have been indicative of distress (Faber-Langendoen, 1994). On the other hand, family members may especially want for their loved one to be free of tubes before he or she dies and to be able to give a kiss or caress that would be hard to do with a tube in the loved one's mouth. It is worth asking family members before presuming to know the best plan.
Extubation may be relevant for patients who will experience distress from the endotracheal tube. The adequacy of the gag and cough reflexes, volume of pulmonary secretions, duration of intubation, and patient consciousness should be considered when determining whether extubation should be performed (Campbell and Carlson, 1992).
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved. For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ]. |
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