EEPPEECC

EEPPEECC

Withholding, Withdrawing Therapy

Withholding, Withdrawing Therapy

Module 11Module 11Module 11Module 11

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

ObjectivesObjectives

Know the principles for withholding Know the principles for withholding or withdrawing therapyor withdrawing therapy

Apply these principles to the Apply these principles to the withholding or withdrawal ofwithholding or withdrawal of

artificial feeding, hydrationartificial feeding, hydration

ventilationventilation

cardiopulmonary resuscitationcardiopulmonary resuscitation

Know the principles for withholding Know the principles for withholding or withdrawing therapyor withdrawing therapy

Apply these principles to the Apply these principles to the withholding or withdrawal ofwithholding or withdrawal of

artificial feeding, hydrationartificial feeding, hydration

ventilationventilation

cardiopulmonary resuscitationcardiopulmonary resuscitation

Role of the physician . . .Role of the physician . . .

The physician helps the patient and The physician helps the patient and family family

elucidate their own valueselucidate their own values

decide about life-sustaining decide about life-sustaining treatmentstreatments

dispel misconceptionsdispel misconceptions

Understand goals of careUnderstand goals of care

Facilitate decisions, reassess Facilitate decisions, reassess regularlyregularly

The physician helps the patient and The physician helps the patient and family family

elucidate their own valueselucidate their own values

decide about life-sustaining decide about life-sustaining treatmentstreatments

dispel misconceptionsdispel misconceptions

Understand goals of careUnderstand goals of care

Facilitate decisions, reassess Facilitate decisions, reassess regularlyregularly

. . . Role of the physician. . . Role of the physician

Discuss alternativesDiscuss alternatives

including palliative and hospice careincluding palliative and hospice care

Document preferences, medical Document preferences, medical ordersorders

Involve, inform other team membersInvolve, inform other team members

Assure comfort, nonabandonmentAssure comfort, nonabandonment

Discuss alternativesDiscuss alternatives

including palliative and hospice careincluding palliative and hospice care

Document preferences, medical Document preferences, medical ordersorders

Involve, inform other team membersInvolve, inform other team members

Assure comfort, nonabandonmentAssure comfort, nonabandonment

Common concerns . . .Common concerns . . .

Legally required to “do everything?”Legally required to “do everything?”

Is withdrawal, withholding Is withdrawal, withholding euthanasia?euthanasia?

Are you killing the patient when you Are you killing the patient when you remove a ventilator or treat pain?remove a ventilator or treat pain?

Legally required to “do everything?”Legally required to “do everything?”

Is withdrawal, withholding Is withdrawal, withholding euthanasia?euthanasia?

Are you killing the patient when you Are you killing the patient when you remove a ventilator or treat pain?remove a ventilator or treat pain?

. . . Common concerns. . . Common concerns

Can the treatment of symptoms Can the treatment of symptoms constitute euthanasia?constitute euthanasia?

Is the use of substantial doses of Is the use of substantial doses of opioids euthanasia?opioids euthanasia?

Can the treatment of symptoms Can the treatment of symptoms constitute euthanasia?constitute euthanasia?

Is the use of substantial doses of Is the use of substantial doses of opioids euthanasia?opioids euthanasia?

Life-sustaining treatmentsLife-sustaining treatments ResuscitationResuscitation

Elective intubationElective intubation

SurgerySurgery

DialysisDialysis

Blood Blood transfusions, transfusions, blood productsblood products

ResuscitationResuscitation

Elective intubationElective intubation

SurgerySurgery

DialysisDialysis

Blood Blood transfusions, transfusions, blood productsblood products

Diagnostic testsDiagnostic tests

Artificial nutrition, Artificial nutrition, hydrationhydration

AntibioticsAntibiotics

Other treatmentsOther treatments

Future hospital, Future hospital, ICU admissionsICU admissions

Diagnostic testsDiagnostic tests

Artificial nutrition, Artificial nutrition, hydrationhydration

AntibioticsAntibiotics

Other treatmentsOther treatments

Future hospital, Future hospital, ICU admissionsICU admissions

8-step protocol to discuss treatment preferences . . .8-step protocol to discuss treatment preferences . . .

1.1. Be familiar with policies, statutes Be familiar with policies, statutes

2.2. Appropriate setting for the Appropriate setting for the discussiondiscussion

3.3. Ask the patient, family what they Ask the patient, family what they understandunderstand

4.4. Discuss general goals of care Discuss general goals of care

1.1. Be familiar with policies, statutes Be familiar with policies, statutes

2.2. Appropriate setting for the Appropriate setting for the discussiondiscussion

3.3. Ask the patient, family what they Ask the patient, family what they understandunderstand

4.4. Discuss general goals of care Discuss general goals of care

. . . 8-step protocol to discuss treatment preferences

. . . 8-step protocol to discuss treatment preferences5.5. Establish context for the discussion Establish context for the discussion

6.6. Discuss specific treatment Discuss specific treatment preferencespreferences

7.7. Respond to emotions Respond to emotions

8.8. Establish and implement the plan Establish and implement the plan

5.5. Establish context for the discussion Establish context for the discussion

6.6. Discuss specific treatment Discuss specific treatment preferencespreferences

7.7. Respond to emotions Respond to emotions

8.8. Establish and implement the plan Establish and implement the plan

Aspects of informed consentAspects of informed consent Problem treatment would addressProblem treatment would address

What is involved in the treatment / What is involved in the treatment / procedureprocedure

What is likely to happen if the patient What is likely to happen if the patient decides not to have the treatmentdecides not to have the treatment

Treatment benefitsTreatment benefits

Treatment burdensTreatment burdens

Problem treatment would addressProblem treatment would address

What is involved in the treatment / What is involved in the treatment / procedureprocedure

What is likely to happen if the patient What is likely to happen if the patient decides not to have the treatmentdecides not to have the treatment

Treatment benefitsTreatment benefits

Treatment burdensTreatment burdens

Example 1: Artifical feeding, hydrationExample 1: Artifical feeding, hydration Difficult to discussDifficult to discuss

Food, water are symbols of caring Food, water are symbols of caring

Difficult to discussDifficult to discuss

Food, water are symbols of caring Food, water are symbols of caring

Review goals of careReview goals of care

Establish overall goals of careEstablish overall goals of care

Will artificial feeding, hydration help Will artificial feeding, hydration help achieve these goals?achieve these goals?

Establish overall goals of careEstablish overall goals of care

Will artificial feeding, hydration help Will artificial feeding, hydration help achieve these goals?achieve these goals?

Address misperceptionsAddress misperceptions

Cause of poor appetite, fatigueCause of poor appetite, fatigue

Relief of dry mouthRelief of dry mouth

DeliriumDelirium

Urine outputUrine output

Cause of poor appetite, fatigueCause of poor appetite, fatigue

Relief of dry mouthRelief of dry mouth

DeliriumDelirium

Urine outputUrine output

Help family with need to give careHelp family with need to give care Identify feelings, emotional needsIdentify feelings, emotional needs

Identify other ways to demonstrate Identify other ways to demonstrate caringcaring

teach the skills they needteach the skills they need

Identify feelings, emotional needsIdentify feelings, emotional needs

Identify other ways to demonstrate Identify other ways to demonstrate caringcaring

teach the skills they needteach the skills they need

Normal dyingNormal dying Loss of appetiteLoss of appetite

Decreased oral fluid intakeDecreased oral fluid intake

Artificial food / fluids may make Artificial food / fluids may make situation worsesituation worse

breathlessnessbreathlessness

edemaedema

ascitesascites

nausea / vomitingnausea / vomiting

Loss of appetiteLoss of appetite

Decreased oral fluid intakeDecreased oral fluid intake

Artificial food / fluids may make Artificial food / fluids may make situation worsesituation worse

breathlessnessbreathlessness

edemaedema

ascitesascites

nausea / vomitingnausea / vomiting

Example 2: Ventilator withdrawalExample 2: Ventilator withdrawal Rare, challengingRare, challenging

Ask for assistanceAsk for assistance

Assess appropriateness of requestAssess appropriateness of request

Role in achieving overall goals of Role in achieving overall goals of carecare

Rare, challengingRare, challenging

Ask for assistanceAsk for assistance

Assess appropriateness of requestAssess appropriateness of request

Role in achieving overall goals of Role in achieving overall goals of carecare

Immediate extubationImmediate extubation

Remove the endotracheal tube after Remove the endotracheal tube after appropriate suctioningappropriate suctioning

Give humidified air or oxygen to Give humidified air or oxygen to prevent the airway from dryingprevent the airway from drying

Ethically sound practiceEthically sound practice

Remove the endotracheal tube after Remove the endotracheal tube after appropriate suctioningappropriate suctioning

Give humidified air or oxygen to Give humidified air or oxygen to prevent the airway from dryingprevent the airway from drying

Ethically sound practiceEthically sound practice

Terminal weaningTerminal weaning

Rate, PEEP, oxygen levels are Rate, PEEP, oxygen levels are decreased firstdecreased first

Over 30–60 minutes or longerOver 30–60 minutes or longer

A Briggs T piece may be used in A Briggs T piece may be used in place of the ventilatorplace of the ventilator

Patients may then be extubatedPatients may then be extubated

Rate, PEEP, oxygen levels are Rate, PEEP, oxygen levels are decreased firstdecreased first

Over 30–60 minutes or longerOver 30–60 minutes or longer

A Briggs T piece may be used in A Briggs T piece may be used in place of the ventilatorplace of the ventilator

Patients may then be extubatedPatients may then be extubated

Ensure patient comfortEnsure patient comfort

Anticipate and prevent discomfortAnticipate and prevent discomfort

Have anxiolytics, opioids Have anxiolytics, opioids immediately availableimmediately available

Titrate rapidly to comfortTitrate rapidly to comfort

Be present to assess, reevaluateBe present to assess, reevaluate

Anticipate and prevent discomfortAnticipate and prevent discomfort

Have anxiolytics, opioids Have anxiolytics, opioids immediately availableimmediately available

Titrate rapidly to comfortTitrate rapidly to comfort

Be present to assess, reevaluateBe present to assess, reevaluate

Prevent symptomsPrevent symptoms

BreathlessnessBreathlessness

opioidsopioids

AnxietyAnxiety

benzodiazepinesbenzodiazepines

BreathlessnessBreathlessness

opioidsopioids

AnxietyAnxiety

benzodiazepinesbenzodiazepines

Preparing for ventilator withdrawalPreparing for ventilator withdrawal Determine degree of desired Determine degree of desired

consciousnessconsciousness

Bolus 2-20 mg morphine IV, then Bolus 2-20 mg morphine IV, then continuous infusioncontinuous infusion

Bolus 1-2 mg midazolam IV, then Bolus 1-2 mg midazolam IV, then continuous infusioncontinuous infusion

Titrate to degree of consciousness, Titrate to degree of consciousness, comfortcomfort

Determine degree of desired Determine degree of desired consciousnessconsciousness

Bolus 2-20 mg morphine IV, then Bolus 2-20 mg morphine IV, then continuous infusioncontinuous infusion

Bolus 1-2 mg midazolam IV, then Bolus 1-2 mg midazolam IV, then continuous infusioncontinuous infusion

Titrate to degree of consciousness, Titrate to degree of consciousness, comfortcomfort

Prepare the family . . .Prepare the family . . .

Describe the procedureDescribe the procedure

Reassure that comfort is a primary Reassure that comfort is a primary concernconcern

Medication is availableMedication is available

Patient may need to sleep to be Patient may need to sleep to be comfortablecomfortable

Describe the procedureDescribe the procedure

Reassure that comfort is a primary Reassure that comfort is a primary concernconcern

Medication is availableMedication is available

Patient may need to sleep to be Patient may need to sleep to be comfortablecomfortable

. . . Prepare the family. . . Prepare the family

Involuntary movementsInvoluntary movements

Provide love and supportProvide love and support

Describe uncertaintyDescribe uncertainty

Involuntary movementsInvoluntary movements

Provide love and supportProvide love and support

Describe uncertaintyDescribe uncertainty

Prior to withdrawalPrior to withdrawal

Prior to procedurePrior to procedure

discussion and agreement to discussion and agreement to discontinue discontinue

with patient (if conscious)with patient (if conscious)

with family, nurses, respiratory with family, nurses, respiratory therapiststherapists

document on the patient’s chartdocument on the patient’s chart

Prior to procedurePrior to procedure

discussion and agreement to discussion and agreement to discontinue discontinue

with patient (if conscious)with patient (if conscious)

with family, nurses, respiratory with family, nurses, respiratory therapiststherapists

document on the patient’s chartdocument on the patient’s chart

Withdrawal protocol– part 1Withdrawal protocol– part 1 ProcedureProcedure

shut off alarmsshut off alarms

remove restraints remove restraints

NG tube is removed NG tube is removed

family is invited into the roomfamily is invited into the room

pressors are turned offpressors are turned off

parents may hold childparents may hold child

ProcedureProcedure

shut off alarmsshut off alarms

remove restraints remove restraints

NG tube is removed NG tube is removed

family is invited into the roomfamily is invited into the room

pressors are turned offpressors are turned off

parents may hold childparents may hold child

Withdrawal protocol–part 2Withdrawal protocol–part 2 Establish adequate symptom control Establish adequate symptom control

prior to extubationprior to extubation

Have medications IN HAND Have medications IN HAND

midazolam, lorazepam, or diazepam midazolam, lorazepam, or diazepam

Set FiOSet FiO22 to 21% to 21%

Adjust medications Adjust medications

Remove the ET tubeRemove the ET tube

Establish adequate symptom control Establish adequate symptom control prior to extubationprior to extubation

Have medications IN HAND Have medications IN HAND

midazolam, lorazepam, or diazepam midazolam, lorazepam, or diazepam

Set FiOSet FiO22 to 21% to 21%

Adjust medications Adjust medications

Remove the ET tubeRemove the ET tube

Withdrawal protocol– part 3 . . .Withdrawal protocol– part 3 . . . Invite family to bedsideInvite family to bedside

Washcloth, oral suction catheter, Washcloth, oral suction catheter, facial tissuesfacial tissues

Reassess frequentlyReassess frequently

Invite family to bedsideInvite family to bedside

Washcloth, oral suction catheter, Washcloth, oral suction catheter, facial tissuesfacial tissues

Reassess frequentlyReassess frequently

. . . Withdrawal protocol– part 3. . . Withdrawal protocol– part 3 After the patient diesAfter the patient dies

talk with family and stafftalk with family and staff

provide acute grief supportprovide acute grief support

Offer bereavement support to family Offer bereavement support to family membersmembers

follow up to ensure they are okayfollow up to ensure they are okay

After the patient diesAfter the patient dies

talk with family and stafftalk with family and staff

provide acute grief supportprovide acute grief support

Offer bereavement support to family Offer bereavement support to family membersmembers

follow up to ensure they are okayfollow up to ensure they are okay

Example 3: Cardiopulmonary resuscitationExample 3: Cardiopulmonary resuscitation

Establish general goals of careEstablish general goals of care

Use understandable languageUse understandable language

Avoid implying the impossibleAvoid implying the impossible

Ask about other life-prolonging Ask about other life-prolonging therapiestherapies

Affirm what you will be doingAffirm what you will be doing

Establish general goals of careEstablish general goals of care

Use understandable languageUse understandable language

Avoid implying the impossibleAvoid implying the impossible

Ask about other life-prolonging Ask about other life-prolonging therapiestherapies

Affirm what you will be doingAffirm what you will be doing

Write appropriate medical ordersWrite appropriate medical orders DNRDNR

DNIDNI

Do not transferDo not transfer

OthersOthers

POLSTPOLST

DNRDNR

DNIDNI

Do not transferDo not transfer

OthersOthers

POLSTPOLST

EEPPEECC

EEPPEECC Withholding, Withholding,

Withdrawing Withdrawing Therapy Therapy

SummarySummary

Withholding, Withholding, Withdrawing Withdrawing Therapy Therapy

SummarySummary