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124 PART 1: An Overview of the Approach to and Organization of Critical Care

these disagreements and quantitative evidence suggests CPR among TABLE 18-3 Suggested Components for a Withdrawal of Life-Sustaining
ICU patients, especially those receiving vasopressors, has little benefit ICU Treatments Protocol
with survival to hospital discharge ranging from 9.3% to 21.2%, with
3.6% of patients on vasopressors who receive CPR being discharged to Stages of the Withdrawal Key Elements and Practical Details
home. Historically, general ethical convention in the United States is Preparation and general 1. Document decision and rationale for withdrawal of life
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that autonomy was the preimminent value and thus drives end-of-life care issues support
treatment decisions. However, many ethicists and professional medical 2. Discuss the withdrawal plan with the interdisciplinary
societies have taken the position that physicians are not obligated to ICU team including nursing and respiratory therapy
provide care that is futile. The American Medical Association rec- 3. Explain to family the process and expected duration of
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ommends that when a patient or surrogate decision maker insists on the process based on the patient’s clinical context
a therapy that the physician believes is futile, a communication and 4. Offer open visitation for family and endorse time for
negotiation process should be initiated to reconcile these differences cultural or religious rituals
and the treatment should be provided until differences are reconciled. 5. Offer appropriate spiritual and/or psychosocial support
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Another approach has been developed in the state of Texas and codified for family (eg, chaplains, palliative care)
into state law: The Texas Advance Directives Act outlines processes 6. Discontinue treatments (eg, vasopressors) and monitor-
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that allow physicians to override the requests of patients or families for ing devices (eg, cardiac monitors) not intended to sup-
treatment deemed futile, while ensuring due process for patients and port goal of comfort excluding mechanical ventilation
families. Debate on the pros and cons of this legislation will no doubt 7. Continue administering analgesic and sedative medi-
continue as consensus is currently lacking on how to best address irre- cations if patient already receiving
solvable conflict between surrogates and clinicians. 107,108 Even though
this debate continues, invoking medical futility to withhold or withdraw Palliative approach to with- 1. Ensure neuromuscular blockade is not being administered
life-sustaining treatments against the wishes of a patient or surrogate drawal of mechanical 2. Ensure analgesic and sedative medications are avail-
decision maker is rarely necessary if clinician communication has been ventilation able in intravenous bolus formulations
good and if building trust has been a focus of the clinical team. 3. Reduce Fi o 2 to room air and PEEP to 0 and treat signs of
dyspnea with opioids and anxiety with sedatives
■ PRACTICAL ASPECTS OF WITHHOLDING 4. Sequentially reduce the amount of respiratory support
OR WITHDRAWING LIFE-SUSTAINING THERAPY provided by the ventilator and treat signs of distress
if/when they emerge (eg, change mode to pressure
If the determination is made to withdraw life-sustaining treatments, support and progressively reduce amount of positive
the process by which this is carried out should adhere to the expected pressure from 20 to 0 mm H O
2
standards for quality medical care including appropriate documentation, 5. Monitor for signs of distress throughout terminal
attention to detail, an explicit plan, and interdisciplinary implementa- discontinuation process including respiratory rate >20
tion. Communication with families should include information about breaths/minute; accessory muscle use; nasal flaring;
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how the withdrawal process will proceed, assurances that symptoms will facial grimacing
be identified and treated appropriately, and, if the family wishes to be 6. Treat symptoms as necessary with each incremental
with the patient after withdrawal of life support, information on what decrease in ventilatory support
dying looks like. The rationale and decision-making process behind the Airway management 1. Consider prophylactic medication (eg, scopolamine)
decision to withdraw life support should be documented in the patient’s for excessive secretions if apparent or anticipated
medical record. (eg, pulmonary edema)
There are limited data to guide clinicians in the practical aspects
of withdrawal of life support but because abrupt discontinuation of 2. Families report greater satisfaction with the quality of
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dying when endotracheal tubes (ET) are removed
mechanical ventilation can be associated with substantial suffering, 3. If the patient is at risk for abrupt airway collapse,
development and utilization of a protocol are reasonable and several are consider retaining endotracheal tube (eg, major neu-
available online from the Center to Advance Palliative Care’s Improving rologic injury)
Palliative Care in the ICU Project (IPAL-ICU). Detailed protocols can be
found in the section on policies/protocols entitled “Withdrawal of Life
Support Orders” and “Withdrawal of Mechanical Ventilation Protocol.” higher when patients are extubated, but the observational nature of such
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A life support withdrawal order form was evaluated in a before- studies limits conclusions. The decision to extubate should, therefore,
112
after study and found to be helpful to ICU physicians and nurses. be made on an individual basis depending on the anticipated time to
113
Additionally, although the use of opioids and benzodiazepines increased death and family preferences regarding the endotracheal tube and the
in the after group, time to death was unchanged, suggesting the use of potential for distressing sounds of respirations.
the protocol did not hasten death. 113 The entire process typically requires 10 to 20 minutes and the time
Table 18-3 provides the steps generally included in protocols/order between withdrawal of ventilation and death for most patients is in the
forms for withdrawal of life-sustaining ICU treatments and breaks these range of 1 to 6 hours. However, some patients may survive consider-
47
steps into three stages. First, preparation and general care issues should ably longer and the clinical team and the family should be prepared for
be attended to. These include communication, counseling, and support this possibility.
of the family, as well as discussion among the interdisciplinary ICU
team. Treatments and monitoring devices not congruent with a goal SUMMARY
of palliation should be discontinued except the ventilator. Second, a
stepwise and sequential approach to terminal ventilator discontinuation Chronic and progressive diseases are the most common causes of death
should be used to get the patient comfortably off mechanical ventilation in the developed world and in the United States this prompts a reliance
through administering analgesics and sedatives as needed, based on on acute care hospitals as a common location for death. Thus, ICUs play
signs and symptoms of distress. a central role in end-of-life care and this will likely remain the case as
Limited data exist as to whether patients should be extubated after patients, families, and clinicians continue to grapple with the complex
terminal discontinuation of mechanical ventilation. Small studies have processes of shared decision making in the context of a multicultural
found no significant difference in patient comfort, but lack power to and multireligion milieu. End-of-life care in ICUs often includes with-
detect clinically important differences. Families rate quality of dying holding or withdrawing life-sustaining treatments and ICU clinicians
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