1. How to Withdraw the Ventilator: Is there an optimal way? Patsy D. Treece RN, MN Critical Care Research Nurse Division of Pulmonary/Critical Care Harborview Medical Center

2. Getting to Withdrawal Withdrawal/withholding unwanted treatments is legal and ethical Family members may have widely different views of what pt would want Health Care providers also differ widely in their view of what is the right thing to do in different cases

3. Death in the ICU is common Over 500,000 patients each year in the US die in a hospitalization associated with an ICU admission 46% of patients received mechanical ventilation and 38% prolonged ICU stays before death Support 1995

4. Withdrawal of Life Support is Common A number of studies in North America and Europe that show that –withdrawal of life sustaining treatment occurs in 70 - 90% of all ICU deaths –CPR is rare and occurs in a minority of deaths

6. Exaggerated Expectations TV CPR 77% short term survival 37% hospital discharge Real CPR 30% short term survival 5% hospital discharge Diem SJ, Lantos JD, Tulsky JA. NEJM. 1996;334(24):1578-82.

7. Death in the ICU will continue to be common Year 2020: 20% of population over age 65, 8% over age 75 Demand for ICU services will increase as intensive therapy shown effective in older patients Advance care planning and prognostic tools are unlikely to eliminate a trial of intensive care

8. Issues to consider 11% of physicians would not give narcotics to relieve pain if it might result in death 34% of physicians would not withdraw ventilator when requested by a competent, terminally ill patient 50% of conscious patients experienced moderate or severe pain in the last 3 days of life Arch Int Med 153:722, JAMA 267:949, AJRCCM 151:288

9. Standardized Protocols Effective Management of sepsis, prevention of VAP, management of MI etc

10. Evidence of questionable practice Stepped approach to decisions –DNR, dialysis, pressors, antibiotics, ventilator Comfort care included –Pressors, TPN, antibiotics, and laboratory tests Stuttering pressor orders –No second agent, no further increases in dose, wean to off Range of sedation medication –Morphine 0-80 mg/hr, midazolam 0-45mg/hr Faber-Langendoen and Bartels, CCM 1992

11. 1)Goal: remove unwanted and ineffective treatments that no longer provide comfort 2)Withholding treatments is morally and legally equivalent to withdrawing them 3)Actions solely intended to hasten death are not ok 4)Any treatment can be withdrawn 5)Withdrawal of LST is a medical procedure Principles of withdrawing LST

12. Applicable Ethical Principles Autonomy- patient or surrogate Principle of double effect Beneficence/nonmaleficence

13. Standardized Order Set for Withdrawal of Life Support

14.  Do Not Attempt Resuscitation (DNAR) order written  Note written in chart that documents rationale for comfort care, discussions with attending and discussions with family (or attempts to contact family) 1)Discontinue all previous orders including routine vital signs, medication, enteral feeding, intravenous drips, radiographs, laboratory tests. See below for new orders. 2)Remove devices not necessary for comfort including monitors, blood pressure cuffs, and leg compression sleeves. See below for orders related to the ventilator. 3)Remove all devices (cardiac output computer, transfusers, defibrillator, intra-aortic balloon pump, ventricular assist device, temporary pacemaker) from ICU room. 4)Liberalize visitation.

15. SEDATION AND ANALGESIA: Select one:  Morphine drip at current rate (assuming patient comfortable at that dose) or 10 mg/hr or ___mg/hr For signs of discomfort, up to Q 15 min, give additional morphine equal to current hourly drip rate and increase drip by 25%  Fentanyl […]  Other narcotic: Select one:  Lorazepam drip at current rate (assuming patient comfortable at that dose) or 5 mg/hr or ____mg/hr For signs of discomfort, up to Q 15 min, give additional lorazepam equal to current hourly drip rate and increase drip by 25%  Midazolam […]  Other benzodiazepine, barbiturate, or propofol:

16. VENTILATOR: 1)Initial ventilator setting: IMV rate___, PS level ___, (Choose IMV or PS not a combination), F i O 2 ____, PEEP ____. 2)Reduce apnea, heater, and other ventilator alarms to minimum setting. 3)Reduce F i O 2 to room air and PEEP to zero over about 5 minutes and titrate sedation as indicated for discomfort. 4)As indicated by level of discomfort, wean IMV to 4 or PS to 5 over 5 to 20 minutes and titrate sedation as indicated for discomfort. 5)When patient is comfortable on IMV rate 4 or PS of 5, select one:  Extubate patient to air  T-piece with air (not CPAP on ventilator)

17. PRINCIPLES FOR WITHHOLDING AND WITHDRAWING LIFE SUSTAINING TREATMENT Death occurs as a complication of the underlying disease. The goal of the comfort care outlined on the reverse is to relieve suffering in a dying patient not to hasten death. Withdrawal of life sustaining treatment is a medical procedure that requires the same degree of physician participation and quality as other procedures. Actions solely intended to hasten death (for example, high doses of potassium or paralytic drugs) are morally unacceptable, however, any dose of pain relieving medication can be used when required to provide comfort even if these doses may hasten death.

18. Concerns about hastening death by over-sedating patients are understandable. However, clinicians should be extremely sensitive to the difficulties of assessing discomfort in critically ill patients and should know that many patients develop tolerance to sedative medication. Therefore, clinicians should be wary of under-treating discomfort during the withdrawal of life sustaining treatments in the ICU. Brain dead patients do not need sedation during the withdrawal of life sustaining treatment. Patients should not have life support withdrawn while receiving paralytic drugs as these will mask signs of discomfort. Life support can be withdrawn from patients after paralytic drugs have been stopped as long as clinicians feel that the patient has sufficient motor activity to demonstrate discomfort.

19. Withholding treatments is morally and legally equivalent to withdrawing them. When one life sustaining treatment is withheld, strong consideration should be given to withdrawing other current life sustaining treatments and changing the goals of care to comfort. Any treatment can be withdrawn including nutrition, fluids, antibiotics, and blood. Assessing pain and discomfort in intubated, critically ill, patients can be difficult. The following should be assessed and documented in the medical record when increasing sedation: tachypnea, tachycardia, diaphoresis, grimacing, accessory muscle use, nasal flaring, and restlessness.

20. How much sedation is enough? Wide range of doses reported in literature is understandable Prolonged ICU sedation can lead to tolerance and large doses may be necessary to relieve symptoms No dose is “too much” if lower doses fail Some techniques are unacceptable –Induction dose intended to induce apnea –Potassium or paralytic drugs to hasten death

21. How to turn the dials… Three choices –Weaning –Stuttering (aka Bargaining) –Off

22. Choosing how to turn the dials Weaning Stuttering –Progressive decisions to withhold combined with weaning –No second pressor, maximum pressor dose –Withhold surgery but continue dialysis –One-way PEEP wean

23. Choosing how to turn the dials Weaning Stuttering Turning off –The only justification for weaning LST is when its abrupt removal will cause discomfort Weaning allows sufficient time to medicate –All LST except ventilator can just be turned off: pressors, pacemaker, fluids, dialysis –Only justification for stuttering withdrawal is as negotiated settlement with family

24. The Dance Be prepared with meds/staff Communicate with each other Start drips before making changes- attain comfort Compare observations and manage sedation and vent changes in a coordinated fashion together

25. What about the endotracheal tube? Little evidence to guide decisions Clinicians frequently and families occasionally have strong opinions Ethically defensible to keep or remove Management of the airway may not be that important if other steps in removing ventilatory support are performed compassionately and efficiently

26. Special cases Brain death Chronic lung disease Paralysis and muscle weakness

27. Complication Unpredicted Long term survival

28. Changing Ideas about Withdrawing LST Not a failure Is another skill that can be learned and improved upon Is a valid medical procedure Institutional practices evolving Support colleagues who are good- mentor

29. Contact info ptreece@u.washington.edu http://depts.washington.edu/eolcare/