Terminal Extubation Alia Tuqan, M.D.

Goals and objectives Discuss withdrawal of ventilator when patients are at end of life Understand the ethical issues related to withdrawal of mechanical ventilator Review methods and treatments to keep patients comfortable when withdrawing ventilator

Introduction The cessation of mechanical ventilation (MV) after goals of care for a patient have changed to comfort A.k.a., terminal weaning when the patient is titrated off MV over a short period of time Avoid using the term withdrawal of care with the patients and their families as care still will be administered to the patients after the terminal extubation

Ethical Issues Beneficence – doing good by the patient Non-maleficence – doing no harm Autonomy – patients have the right to refuse treatment, including that which is life sustaining Medical equivalence – withholding and withdrawing MV are thought of as equal Sometimes patients’ families have reservations about stopping a therapy that was already started It can be useful to tell them that withdrawing mechanical ventilation can be thought of as similar to never starting it or do-not-intubate (DNI)

Ethical Issues Principle of Double Effect – terminal extubation is permissible as it is intended to relieve suffering even though the undesired consequence may be to hastened death Allowing to die versus killing Terminal extubation allows for a patient to have a natural death versus euthanasia, intentionally ending a patient’s life, which does not

Preparation Educate the patients and their families on what to expect Explain the procedure in clear, simple terms Highlight that the patients will be kept comfort throughout the process Discuss prognosis – sometimes patients decline rapidly over minutes to hours while others will live for longer periods, such as days Educate the patients’ families on agonal breathing

Preparation Allow the patients and their families time and space to process, e.g., say their goodbyes or do spiritual rituals Agree on a specific time that works for the patients, their families and the healthcare providers This allows the patients and their families to visit prior It is best to choose a time, e.g., the morning, when the hospital is fully staffed Make sure the healthcare providers are prepared Nurses should be available to administer medications Respiratory therapists should be called to bedside to assist 

Preparation Patients should have a single-occupancy room in a quiet location Patients should have IV access Neuromuscular blocking agents or paralytic medications should be discontinued In theory, paralytics could hasten a patient’s death by decreasing ability to breathe, and, therefore, should be stopped Patients on paralytics may look comfortable However, in reality, comfort is difficult to assess Patients’ symptoms may be masked because patients are unable to express pain or other symptoms

Preparation An end-of-life (EOL) protocol should be followed Vital signs should be discontinued Ventilator and other alarms should be turned off In addition to MV, other life-sustaining treatments (e.g., vasopressors and antibiotics) should be stopped Other palliative measures should be in place e.g., pain should be controlled with analgesics Painful tasks (e.g., wound care and turning) should be minimized

Protocols Medical centers often have standard protocols for physicians and respiratory therapists to follow The endotracheal tube may be kept in place or removed if the tube is removed, the cuff should be deflated prior MV parameters (e.g., respiratory rate and tidal volume) may be titrated down gradually (terminal weaning) or MV may be stopped abruptly once the patient is comfortable (immediate extubation)

Protocols With tracheostomies, the ventilator is stopped and tubing can be disconnected FIO2 is set to 21% Humidified oxygen is used

Medications Symptoms related to terminal extubation can include pain, dyspnea and agitation Therefore, protocols typically include analgesics, anxiolytics, and/or anesthetics/sedatives The principle of anticipatory dosing (administering medications in anticipation of symptoms) should be followed

Protocols: Option 1 Opioid + benzodiazepine Usually first line E.g., morphine + lorazepam or midazolam Bolus 15 minutes prior to the procedure After bolusing, the patient can be started on an opioid drip which can be up-titrated to comfort and spot-dosed benzodiazepines For a non-opioid naïve patient, the patient may need to be given a larger bolus and basal rate of opioids

Protocols: Option 2 Opioid + barbiturate Usually second line when benzodiazepine cannot be used E.g., phenobarbital

Protocols: Option 3 Opioid + anesthetic Usually third line E.g., propofol Can be considered palliative sedation (PS) Check with your medical center re: administration policies Useful for patients who may be conscious and in severe distress not controlled by other measures

Palliative Sedation Using sedation to relieve a patient’s uncontrollable physical symptoms typically at the EOL Benzodiazepines, barbiturates and anesthetics are typically used When PS is being considered, physicians need to have conversations with patients and families re: PS’ purpose of alleviating symptoms It may be necessary to distinguish between PS and euthanasia PS versus euthanasia Relieving a patient’s physical symptoms at the EOL versus intentionally ending a patient’s life to relieve a patient’s physical symptoms Not hastening death versus hastening death

Properly Dosed Medications Do Not Hasten Death Mazer et al, 2011 showed that higher doses of opioids were associated with delays in death Pre-extubation, for each 1mg/hr increment of morphine, there was a 7.9 minute delay in death Pre- versus post-extubation, for each 1mg/hr increment of morphine, there was a 12.2 minute delay in death

Properly Dosed Medications Do Not Hasten Death Chan et al, 2004 showed that higher doses of benzodiazepines were associated with delays in death Pre- versus post-extubation, for each 1mg/hr increment of lorazepam, there was a 13 minute delay in death There was no relationship between doses of narcotics and time of death

Respiratory Distress It’s important to assess and treat Possible markers: Tachypnea Tachycardia Grimacing Diaphragmatic or paradoxical breathing Use of accessory muscles Nasal flaring Truog, 2004

References J. Andrew Billings. Humane terminal extubation reconsidered: The role for preemptive analgesia and sedation. Critical Care Medicine. 2012; 40(2): 625-630. J. Andrew Billings. Terminal Extubation of the Alert Patient. Journal of Palliative Medicine. 2011; 14(7): 800-801.  J. Andrew Billings and Larry R. Churchill. Monolithic Moral Frameworks: How Are the Ethics of Palliative Sedation Discussed in the Clinical Literature?” Journal of Palliative Medicine. 2012; 15(6): 709-713. Jeannie D. Chan, Patsy D. Treece, Ruth A. Engelberg, Lauren Crowley, Gordon D. Rubenfield, Kenneth P. Steinberg, and J. Randall Curtis. Narcotic and Benzodiazepine Use After Withdrawal of Life Support. Chest. 2004; 126: 286-293. Mark A. Mazer, Chad M. Alligood, and Qiang Wu. The Infusion of Opioids During Terminal Withdrawal of Mechanical Ventilation in the Medical Intensive Care Unit. Journal of Pain and Symptom Management. 2011; 42(1): 44-51. Ryan R. Nash and Leonard J. Nelson. U6: Ethical and Legal Issues. American Academy of Hospice and Palliative Medicine. 2012. Joseph Shiga. Discontinuation of Technological Support. AAHPM Intensive Board Review Course DVD. 2012.

References Robert D. Truog, Margaret L. Campbell, J. Randall Curtis, Curtis E. Haas, John M. Luce, Gordon D. Rubenfield, Cynda Hylton Rushton, and David C. Kaufman. Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine. 2008; 36(3): 953-963. Rodney O. Tucker and Ashley C. Nichols. U4: Managing Non-Pain Symptoms. American Academy of Hospice and Palliative Medicine. 2012. Charles von Gunten and David E. Weissman. #33: Ventilator Withdrawal Protocol, 2nd edition. Fast Facts and Concepts. End of Life/Palliative Education Resource Center, Medical College of Wisconsin. Charles von Gunten and David E. Weissman. #34: Symptom Control for Ventilator Withdrawal in the Dying Patient, 2nd edition. Fast Facts and Concepts. End of Life/Palliative Education Resource Center, Medical College of Wisconsin. Charles von Gunten and David E. Weissman. #35: Information for Patients and Families About Ventilator Withdrawal, 2nd edition. Fast Facts and Concepts. End of Life/Palliative Education Resource Center, Medical College of Wisconsin.