Fast Fact and Concept #33: Ventilator Withdrawal Protocol (Part I)

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Title: Fast Fact and Concept #33: Ventilator Withdrawal Protocol (Part I)

Author(s): von Gunten, Charles; Weissman, David E

Note: This is Part I of a three-part series; Part II will review use of sedating medication for ventilator withdrawal (Fast Fact #34) and Part III will review information for families (Fast Fact #35).

Once it is decided that further aggressive medical care is incapable of meeting the desired goals of care for a ventilator-dependent patient, discussing ventilator withdrawal to allow death is appropriate (see Fast Fact #16: Conducting a Family Conference). Such a decision is never easy for family members, doctors, nurses, and other critical care staff. All members of the care team should be involved and appraised of the decision-making process and have the opportunity to discuss the plan of care.

Options for Ventilator Withdrawal. Two methods have been described: Immediate extubation and terminal weaning. The clinician's and patient's comfort, and the family's perceptions, should influence the choice. In immediate extubation, the endotracheal tube is removed after appropriate suctioning. Humidified air or oxygen is given to prevent the airway from drying. This is the preferred approach to relieve discomfort if the patient is conscious, the volume of secretions is low, and the airway is unlikely to be compromised after extubation. In terminal weaning, the ventilator rate, positive end-expiratory pressure (PEEP), and oxygen levels are decreased while the endotracheal tube is left in place. Terminal weaning may be carried out over a period of as little as 30 to 60 minutes or longer (see ref. 2. for protocol). If the patient survives and it is decided to leave the endotracheal tube in place, a Briggs T-piece can be placed.

Prior to Immediate Ventilator Withdrawal
1. Encourage family to make arrangements for special music or rituals that may be important to them. If the patient is a child, ask parents if they would like to hold the child as he or she dies. Make arrangements for young siblings to have their own support if they are to be present. (See Part III of this series for additional information for families)
2. Document clinical findings, discussion with families/surrogates, and care plan in the patient's chart.
3. The physician should personally supervise that all monitors and alarms in the room are turned off. Ensure that staff is assigned to override alarms that cannot be turned off if they are triggered.
4. Remove any restraints. Remove unnecessary medical paraphernalia (e.g. NG tube, venous compression device).
5. Turn off blood pressure support medications, paralytic medication and discontinue other life-sustaining treatments (e.g. artificial nutrition/hydration, antibiotics, dialysis). Note: some families have difficulty accepting discontinuation of hydration/nutrition-these can be left in place if desired.
6. Maintain intravenous access for administration of palliative medications.
7. Clear a space for family access to the bedside Invite the family into the room. If the patient is an infant or young child, offer to have the parent hold the child.
8. Establish adequate symptom control prior to extubation (See Part II in this series).
9. Have a syringe of a sedating medication at the beside (midazolam, lorazepam) to use in case distressing tachypnea or other symptoms.

At the time of ventilator withdrawal
1. Once you are sure the patient is comfortable, set the FiO2 to .21; observe for signs of respiratory distress; adjust medication as needed to relieve distress before proceeding further.
2. If the patient appears comfortable, prepare to remove the endotracheal tube; try a few moments of "no assist" before the endotracheal tube is removed.
3. A nurse should be stationed at the opposite side of the bed with a washcloth and oral suction catheter.
4. 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.
5. The 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.
6. Be prepared to spend additional time with the family discussing questions concerns. After death occurs, encourage the family to spend as much time at the bedside as they require; provide acute grief support and follow-up bereavement support.

Reference: Adapted from: Emanuel, LL, von Gunten, CF, Ferris, FF (eds.). "Module 11: Withholding and Withdrawing Therapy," The EPEC Curriculum: Education for Physicians on End-of-life Care. www.EPEC.net: The EPEC Project, 1999.

Principles and practice of withdrawing life-sustaining treatment in the ICU. Rubenfeld GD and Crawford SW, in Managing death in the Intensive Care Unit. Curtis JR and Rubenfeld GD (eds) Oxford University Press, 2001 pgs: 127-147.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: von Gunten C and Weissman DE. Fast Facts and Concepts #33: Ventilator Withdrawal Protocol, January, 2001. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 1/2001

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Cardio-pulminary, Cardio-pulmonary diseases, Treatment withdrawal, Treatment withholding

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).