Download Terminal Extubation

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
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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
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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:
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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.