Terminal Extubation Alia Tuqan, M.D. - PowerPoint Presentation

Slide1

Terminal Extubation

Alia Tuqan, M.D.Slide2

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 ventilatorSlide3

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

extubationSlide4

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)Slide5

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 Slide6

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

breathingSlide7

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 Slide8

Preparation

Patients should have a single-occupancy room in a quiet location

P

atients should have IV access

N

euromuscular blocking agents or paralytic medications should be discontinued

I

n theory, paralytics could hasten a patient’s death by decreasing ability to breathe, and, therefore, should be stopped

P

atients on paralytics may look comfortable

H

owever, in reality, comfort is difficult to assess

P

atients’ symptoms may be masked because patients are unable to express pain or other symptomsSlide9

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 minimizedSlide10

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

)Slide11

Protocols

With

tracheostomies

, the ventilator is stopped and tubing can be disconnected

FIO2 is set to 21%

Humidified oxygen is usedSlide12

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 followedSlide13

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 Slide14

Protocols: Option 2

Opioid + barbiturate

Usually

second line when benzodiazepine cannot be used

E.g

., phenobarbital Slide15

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 measuresSlide16

Palliative Sedation

U

sing

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 deathSlide17

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 deathSlide18

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 deathSlide19

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

, 2004Slide20

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. Slide21

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, 2

nd

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, 2

nd

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, 2

nd

edition. Fast Facts and Concepts. End of Life/Palliative Education Resource Center, Medical College of Wisconsin.