3. Withholding, Withdrawing Therapy
The Project to Educate Physicians on End-of-life Care Supported by the American Medical Association and the Robert Wood Johnson Foundation
Module 11
Withholding, Withdrawing Therapy

4. Objectives Know the principles for withholding or withdrawing therapy
Apply these principles to the withholding or withdrawal of
artificial feeding, hydration
ventilation
cardiopulmonary resuscitation

5. Role of the physician . . . The physician helps the patient and family
elucidate their own values
decide about life-sustaining treatments
dispel misconceptions
Understand goals of care
Facilitate decisions, reassess regularly

6. . . . Role of the physician Discuss alternatives
including palliative and hospice care
Document preferences, medical orders
Involve, inform other team members
Assure comfort, nonabandonment

7. Common concerns . . . Legally required to “do everything?”
Is withdrawal, withholding euthanasia?
Are you killing the patient when you remove a ventilator or treat pain?

8. . . . Common concerns
Can the treatment of symptoms constitute euthanasia?
Is the use of substantial doses of opioids euthanasia?

9. Life-sustaining treatments
Resuscitation
Elective intubation
Surgery
Dialysis
Blood transfusions, blood products
Diagnostic tests
Artificial nutrition, hydration
Antibiotics
Other treatments
Future hospital, ICU admissions

10. 8-step protocol to discuss treatment preferences . . .
1. Be familiar with policies, statutes
2. Appropriate setting for the discussion
3. Ask the patient, family what they understand
4. Discuss general goals of care

11. . . . 8-step protocol to discuss treatment preferences
5. Establish context for the discussion
6. Discuss specific treatment preferences
7. Respond to emotions
8. Establish and implement the plan

12. Aspects of informed consent
Problem treatment would address
What is involved in the treatment / procedure
What is likely to happen if the patient decides not to have the treatment
Treatment benefits
Treatment burdens

13. Example 1: Artifical feeding, hydration
Difficult to discuss
Food, water are symbols of caring

14. Review goals of care Establish overall goals of care
Will artificial feeding, hydration help achieve these goals?

15. Address misperceptions
Cause of poor appetite, fatigue
Relief of dry mouth
Delirium
Urine output

16. Help family with need to give care
Identify feelings, emotional needs
Identify other ways to demonstrate caring
teach the skills they need

17. Normal dying Loss of appetite Decreased oral fluid intake
Artificial food / fluids may make situation worse
breathlessness
edema
ascites
nausea / vomiting

18. Example 2: Ventilator withdrawal
Rare, challenging
Ask for assistance
Assess appropriateness of request
Role in achieving overall goals of care

19. Immediate extubation
Remove the endotracheal tube after appropriate suctioning
Give humidified air or oxygen to prevent the airway from drying
Ethically sound practice

20. Terminal weaning Rate, PEEP, oxygen levels are decreased first
Over 30–60 minutes or longer
A Briggs T piece may be used in place of the ventilator
Patients may then be extubated

21. Ensure patient comfort
Anticipate and prevent discomfort
Have anxiolytics, opioids immediately available
Titrate rapidly to comfort
Be present to assess, reevaluate

22. Prevent symptoms
Breathlessness
opioids
Anxiety
benzodiazepines

23. Preparing for ventilator withdrawal
Determine degree of desired consciousness
Bolus 2-20 mg morphine IV, then continuous infusion
Bolus 1-2 mg midazolam IV, then continuous infusion
Titrate to degree of consciousness, comfort

24. Prepare the family . . . Describe the procedure
Reassure that comfort is a primary concern
Medication is available
Patient may need to sleep to be comfortable

25. . . . Prepare the family Involuntary movements
Provide love and support
Describe uncertainty

26. Prior to withdrawal Prior to procedure
discussion and agreement to discontinue
with patient (if conscious)
with family, nurses, respiratory therapists
document on the patient’s chart

27. Withdrawal protocol– part 1
Procedure
shut off alarms
remove restraints
NG tube is removed
family is invited into the room
pressors are turned off
parents may hold child

28. Withdrawal protocol– part 2
Establish adequate symptom control prior to extubation
Have medications IN HAND
midazolam, lorazepam, or diazepam
Set FiO2 to 21%
Adjust medications
Remove the ET tube

29. Withdrawal protocol– part 3 . . .
Invite family to bedside
Washcloth, oral suction catheter, facial tissues
Reassess frequently

30. . . . Withdrawal protocol– part 3
After the patient dies
talk with family and staff
provide acute grief support
Offer bereavement support to family members
follow up to ensure they are okay

31. Example 3: Cardiopulmonary resuscitation
Establish general goals of care
Use understandable language
Avoid implying the impossible
Ask about other life-prolonging therapies
Affirm what you will be doing

32. Write appropriate medical orders
DNR
DNI
Do not transfer
Others
POLST

33. Withholding, Withdrawing Therapy Summary