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  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
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  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
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    Back to Module 11: Withholding/Withdrawing Treatment
    Three Applications

    Example 1: Artificial Feeding and Hydration
    Example 2: Ventilator Withdrawal Techniques for Ventilator Withdrawal Example 3: Cardiopulmonary Resuscitation (CPR)

    Example 2: Ventilator Withdrawal

    A Brief Overview

    • Rare, challenging
    • Ask for assistance
    • Assess appropriateness of request for ventilator withdrawal
    • Role in achieving overall goals of care

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    Techniques for Ventilator Withdrawal

    The clinician’s and patient’s comfort, and the family’s perceptions, should influence the choice of the method to use:

      Immediate Extubation (removal of the endotracheal tube)
    • The endotracheal tube is removed after appropriate suctioning
    • Humidified air or oxygen is given to prevent the airway from drying
    • Ethically sound practice

    While most authorities regard immediate extubation as ethically sound practice, some may be concerned that it is a form of direct killing of the patient. In such an action the intent becomes the primary concern. Secondary consequences can be dealt with, if they occur.

      Terminal Weaning
    • Rate, positive end-expiratory pressure (PEEP), and oxygen levels are decreased first
    • Over 30–60 minutes or longer
    • CO2 narcosis may stimulate endorphin release and further sedate the patient
    • A Briggs T piece may be used in place of the ventilator
    • Patients may then be extubated

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    Ensure Patient Comfort

    • Anticipate and prevent discomfort
    • Have medication immediately available
    • Titrate rapidly to comfort
    • Be present to assess and reevaluate

    When removing a patient from the ventilator, it is critical that the patient be comfortable throughout the procedure and afterwards. The most important and prevalent symptoms are breathlessness and anxiety.

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    Prevent Symptoms

    • Breathlessness
      • Opioids
    • Anxiety
      • Benzodiazepines

    Breathlessness

    Opioids (such as morphine) are the most effective medication for relieving the sense of breathlessness. They work through both central and peripheral mechanisms of action. The principle of intended vs. unintended consequences governs their use in this setting.

    Concerns about unintended secondary effects, such as shortened life, are exaggerated, particularly is established dosing guidelines are followed. Titrate the dose with the intent to achieve comfort. Increased doses beyond the levels needed to achieve comfort or sedation in order to hasten death would constitute euthanasia. Oxygen is helpful to correct hypoxemia, but not necessarily breathlessness.

    Anxiety

    Benzodiazepines (such as midazolam, lorazepam and others) are the most effective anxiolytic drugs in this setting. They are usually used in combination with opioids for severe breathlessness. Opioids only have transient and unreliable anxiolytic effects in opioid-naive patients and should not be used for this purpose.

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    Symptom Management During Withdrawal

    • Determine degree of desired consciousness
    • If the patient is conscious, determine if he or she would like to remain conscious as the ventilator is withdrawn
      • This will determine the endpoints for initial medication and guide the use of additional medication during the procedure

      • If the patient wishes to remain awake, institute opioids and benzodiazepines at low doses
    • Determine, with the patient and family, how and when you would decide to titrate to an endpoint of sedation
    • Before withdrawing the ventilator, ensure that the patient is comfortable
    • Make plans to intervene if severe breathlessness or discomfort ensues after extubation
    • Have medication immediately available at the bedside so that it can be rapidly titrated to the level appropriate to ensure the patient’s comfort
    • Bolus 2–20 mg of morphine IV, then continuous infusion
      • If the patient is naive to opioids and benzodiazepines, start by giving the patient a bolus dose of 2 to 10 mg of morphine IV to prevent breathlessness

      • For children, dose the medications with advice from a pharmacist or pediatric intensivist. Follow this initial dose with a continuous morphine infusion (50% of bolus dose/hr) to maintain the desired effect
    • Bolus 1–2 mg of midazolam IV, then continuous infusion
      • Also, bolus with a dose of 1 to 2 mg of midazolam IV and begin a midazolam infusion at 1 mg/hour

      • Titrate these medications to minimize anxiety and achieve the desired state of comfort and sedation

      • Lorazepam may be used as an alternative

      • If these medications have been in use routinely and pharmacological tolerance has developed, higher doses will be required

      • There is no need to increase the doses once comfort and the desired level of sedation have been achieved
    • Titrate to degree of consciousness and comfort
    • If distress ensues once the ventilator is withdrawn, aggressive symptom control is needed
      • Consider using morphine 5 to 10 mg IV push q 10min and/or midazolam 2 to 4 mg IV push q 10min until distress is relieved

      • Adjust both infusion rates to maintain relief
    • The doses recommended here are for patients who were not previously taking anxiolytic medication or opioids

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    Prepare the Family

    • Ideally, family will be involved in the decision to withdraw the ventilator
    • Need to understand procedure and be reassured about their roles
    • Since there is uncertainty involved, it is also important to prepare the family for the range of outcomes
    • Never make assumptions about what the family understands
    • Describe procedure in clear, simple terms and answer any questions
    • Assure family that the patient’s comfort is of primary concern
    • Explain that breathlessness may occur, but that it can be managed
    • Confirm that you will have medication available to manage any discomfort
    • Ensure they know that you may need to put the patient to sleep
    • Assure them that involuntary moving or gasping does not reflect suffering if the patient is properly sedated or in a coma
    • Explain how family can show love and support through touch, wiping of the patient’s forehead, holding a hand and talking to him or her
    • Ask family what other concerns they have
    • Explain that there is always some uncertainty as to what will happen after the ventilator is withdrawn
      • Some patients die within several minutes

      • Whereas others may live for longer periods

      • Caution the family that, although death is expected, it is not certain

        • Data show that approximately 10% of patients survive and are discharged from the hospital

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    A Suggested Protocol for Ventilator Withdrawal: Immediate Extubation, Unconscious Patient

    This protocol demonstrates how care and planning can ensure that the process of withdrawing life support maintains the dignity of the patient, and involves the family appropriately. The protocol presented is for immediate extubation of an unconscious patient, but it can be adapted for other uses. Key points are listed below

    Prior to Withdrawal

    • Prior to procedure
      • Discussion and agreement to discontinue:

        • With patient (if conscious)
        • With family, nurses, respiratory therapists

      • 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

      • Document issues, clinical findings, and care plan on the patient’s chart

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    Protocol–Part 1

    • Shut off alarms
      • The physician should personally supervise that all monitors and alarms (when possible) in the room are turned off

      • Ensure that staff is assigned to override alarms that cannot be turned off if they are triggered
    • Remove restraints
    • Clear a space for family access to the bedside
    • Before the family comes into the room, remove NG tube and any other needlessly disfiguring or unnecessary device that may be crowding the bedside
    • Family is invited into the room
    • If the patient is an infant or young child, offer to have the parent hold the child
    • Pressors are turned off
    • Maintain intravenous access for administration of palliative medications

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    Protocol–Part 2

    • Establish adequate symptom control prior to extubation
    • Have a syringe of a sedating medication in hand
      • midazolam, lorazepam, or diazepam
    • Once initial symptom control has been established, respirator is set to FiO2 of 21%
    • Observe patient for signs of respiratory distress and adjust medications
    • If a patient is likely to develop CO2 narcosis with a decrease in ventilator settings, there may be less need for sedating medications
    • The ET tube is removed
      • If the patient appears comfortable, prepare to remove the endotracheal tube

      • Or try a few moments of "no assist" before the endotracheal tube is removed

      • When ready to proceed, first deflate the ET tube cuff. (Tip: 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

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    Protocol–Part 3

    • Invite family to come forward to a loved one whose face is no longer encumbered by medical devices
    • Station a nurse at the opposite side of the bed with a washcloth and oral suction catheter, and facial tissues
    • Encourage family to hold the patient’s hand and provide assurances to their loved one
    • Reassess frequently
    • After the patient dies, talk with family and staff
    • Encourage the family to spend as much time at the bedside as they require
    • Provide acute grief support
    • Provide the family with the physician’s name and phone number, if they have any questions
    • Offer follow-up bereavement support
    • Send a bereavement card to family members
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