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

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

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

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

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

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

9. Life-sustaining treatments l Resuscitation l Elective intubation l Surgery l Dialysis l Blood transfusions, blood products l Resuscitation l Elective intubation l Surgery l Dialysis l Blood transfusions, blood products l Diagnostic tests l Artificial nutrition, hydration l Antibiotics l Other treatments l 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 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 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 l Problem treatment would address l What is involved in the treatment / procedure l What is likely to happen if the patient decides not to have the treatment l Treatment benefits l Treatment burdens l Problem treatment would address l What is involved in the treatment / procedure l What is likely to happen if the patient decides not to have the treatment l Treatment benefits l Treatment burdens

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

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

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

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

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

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

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

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

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

22. Prevent symptoms l Breathlessness opioids l Anxiety benzodiazepines l Breathlessness opioids l Anxiety benzodiazepines

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

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

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

26. Prior to withdrawal l Prior to procedure discussion and agreement to discontinue with patient (if conscious) with family, nurses, respiratory therapists document on the patient’s chart l 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 l Procedure shut off alarms remove restraints NG tube is removed family is invited into the room pressors are turned off parents may hold child l 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 l Establish adequate symptom control prior to extubation l Have medications IN HAND midazolam, lorazepam, or diazepam l Set FiO 2 to 21% l Adjust medications l Remove the ET tube l Establish adequate symptom control prior to extubation l Have medications IN HAND midazolam, lorazepam, or diazepam l Set FiO 2 to 21% l Adjust medications l Remove the ET tube

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

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

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

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

33. EPECEPECEPECEPEC EPECEPECEPECEPEC Withholding, Withdrawing Therapy Summary Summary