THE PROCEDURE OF VENTILATOR WITHDRAWAL

KYLE P. EDMONDS, MDDORIS A. HOWELL PALLIATIVE CARE CONSULT SERVICE

UC SAN DIEGO HEALTH SYSTEM

SUMMARY

The withdrawal of mechanical ventilation is a procedure that

requires considerable preparation from all of those involved.

ETHICAL PRINCIPLES

Withdrawing is the same as withholdingPatient autonomy allows for refusal of careClinicians help balance benefit and harmAll patients are entitled to informed consent

INFORMED CONSENT

Ethical & legal requirement

As for any procedure

LEGAL PRINCIPLES

US case law upholds mechanical ventilation as a medical intervention that can be refused

Legal precedent will vary country-to-country

ROLE OF THE TEAM

Help the patient & family • Elucidate their values

• Understand the facts

• Dispel misconceptions

Establish goals of careFacilitate decisionsReassess regularly

COMMON CONCERNS

Am I legally required to ‘do everything’? Is this euthanasia?Am I killing the patient when I withhold or

withdraw ventilatory support?

PROCEDURE OVERVIEW

ChallengingAsk for assistance

Assess appropriateness of request

Role in achieving goals of care

OPTIONS

Immediate• Remove the endotracheal tube

• Give humidified air or oxygen

Weaning• Rate, PEEP, oxygen levels decreased

first

• Over 30–60+ minutes

PRINCIPLES

Treat like any procedureAnticipate &

preparation keyPrevent symptomsTitrate rapidly to

comfortBe present to assess,

reevaluate

PATIENT PREPARATION

Will differ if patient aware

Spiritual needsLoved ones

present

FAMILY PREPARATION

Describe the procedure• Reassure comfort is

primary

• Medications available

• Patient may sleep

Physical Findings• Involuntary movements

• Breathing patterns

FAMILY PREPARATIONDescribe

Uncertainty minutes

hours to days

stabilization

Bedside love & support touch, holding a

hand

talking to patient

Sharing stories

TEAM PREPARATION

Determine the team roles• Chaplaincy

• Nursing

• Pharmacy

• Provider Teams

• Respiratory Therapy

• Social Work

MEDICAL PREPARATION

Determine appropriate degree of consciousness

Titrate to consciousness & comfort

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

Pla

sma

Co

nce

ntr

atio

n

0

Time to Drip Steady State

164 8 12Time ( hours )20 24

50%75%

87.5%93.75%

97%100%

Pain Control

Change GTT

PROTOCOL

Silence alarmsPrepare the

patientTurn off monitorsPrepare the

physical space

PROTOCOL

Ensure symptom control

Have medications IN HAND

Set FiO2 21%

Adjust medications Remove the ET tube

PROTOCOL

Monitor the physical space

Invite family to bedsideWashcloth, oral suction

catheter, facial tissuesReassess frequently

PROTOCOL

After death• Check in

• Allow time

Offer bereavement support

SPECIAL CONSIDERATIONS

Noninvasive ventilatory support

Children

SUMMARY

The withdrawal of mechanical ventilation is a procedure that

requires considerable preparation from all of those involved.

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