Page 569 - Clinical Application of Mechanical Ventilation

Weaning from Mechanical Ventilation 535

Decisions to withdraw life-support measures (e.g., mechanical ventilation, nutri-
Terminal weaning is tional support) have become more common. This trend is partly due to the public’s
defined as withdrawal of
mechanical ventilation that awareness of the quality-of-life issue, and their knowledge that death is an inevitable
results in the death of a process in spite of medical advances, state-of-the-art medical equipment, and pul-
patient.
monary rehabilitation strategies (Jacavone & Young, 1998). It is also partly due to
the availability of living wills, advanced directives, and other options available to the
patient and family members.
When terminal weaning is considered, four concerns must be evaluated and dis-
cussed, where appropriate, with the patient and family members: (1) patient’s in-
formed request, (2) medical futility, (3) reduction of pain and suffering, and (4) fear
and distress (Campbell et al., 1992; Campbell, 2007).
Discussions on a patient’s A patient’s informed consent means that patients agree to have the life-sustaining de-
informed consent should be
done over a period of time vices removed, and that they understand the potential consequences (including death).
so that emotion, pain, and No matter who initiates the discussion, the talk with patients must be open and honest.
other intangible factors do not
interfere with an informed These discussions should also be done over a period of time so that emotion, pain, and
and valid decision. other intangible factors do not interfere with an informed and valid decision.
Terminal weaning may be justified if medical intervention is futile or hopeless.
The interpretation of futility (hopelessness) is based on the past experience of the
Terminal weaning may primary physician or specialist. Schneiderman et al. (1990) suggested that medical
be justified if medical inter- treatments may be futile if physicians have concluded that in the last 100 similar
vention is futile or hopeless.
cases the treatments were useless. This type of objective assessment may be helpful to
the patients or family members who have reservations about terminal weaning and
uncertainties about the chances of recovery.
Another reason for terminal weaning is to stop pain and suffering associated with
Another reason for the disease process (e.g., cancer), medical treatments (e.g., radiation therapy), medi-
terminal weaning is to stop
pain and suffering. cal procedures (e.g., arterial puncture), and psychological trauma (e.g., being totally
dependent on others in an unfamiliar surrounding, unable to care for oneself, to eat,
or to talk).
Physical or verbal clues may uncover that the patient is experiencing distress or
fear of dying. Premedication or medication during and after withdrawal of mechan-
ical ventilation with analgesics and sedatives can be useful in this situation. Dosage
of these medications should be titrated to meet the patient’s need.
Terminal weaning carries many compassionate considerations as well as ethical
and legal implications (Brody et al., 1997; Campbell et al., 1992). Each health care
facility should have resource persons and a standard protocol on terminal weaning
available to the patients and family members, preferably before the needs arise. It is
beyond the scope of this section to cover the ethical implications of terminal wean-
ing in detail. The readers are encouraged to seek other medical ethics resources to
learn more about this topic.

Prior to Withdrawal

Prior to withdrawal of mechanical ventilation, all immediate caregivers who are
uncomfortable with the process should be offered an opportunity to withdraw from
the case. The patient’s pastor or hospital-based chaplain should be notified. The

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