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Fast Fact and Concept #35: Information for patients and families about ventilator withdrawal (Part III)

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Title: Fast Fact and Concept #35: Information for patients and families about ventilator withdrawal (Part III)

Author(s): Charles Von Gunten; David E. Weissman

Note: This is Part III of a three-part series; Part I reviewed a protocol for removing the ventilator (Fast Fact #33), Part II reviewed medications for symptom control (Fast Fact #34).

The physician's counseling of families is a critical aspect of care for the dying patient who is to be removed from a ventilator. Ideally the family will be involved in the decision to withdraw the ventilator and thus appraised of the goals of care. Before withdrawal, the following issues should be discussed.

Potential outcome of ventilator withdrawal
Assuming all other life-sustaining treatments have been stopped, including artificial hydration and nutrition, there are several potential outcomes: rapid death within minutes (typically patients with sepsis on maximal blood pressure support), death within hours to days (see Fast Fact #3: Syndrome of Imminent Death), or stable cardiopulmonary function leading to a different set of care plans, including potential hospital discharge. If the latter possibility is realistic, future management plans should be discussed prior to ventilator removal, since some families may desire to resume certain treatments, notably artificial hydration/nutrition. Generally, by the nature of the underlying illness and the established goals, it is fairly easy to predict which category will be operative, but all families should be prepared for some degree of prognostic uncertainty (see Fast Fact #30: Prognostication).

The procedure of ventilator withdrawal
Never make assumptions about what the family understands; describe the procedure in clear, simple terms and answer any questions. Families should be told before-hand the steps of withdrawal and whether or not it is planned/desired to remove the endotracheal tube [see Fast Fact #33: Ventilator Withdrawal Protocol (Part I)]. In addition, they should be counseled about the use of oxygen and medications for symptom control. Assure them that the patient's comfort is of primary concern. Explain that breathlessness may occur, but that it can be managed. Confirm that you will have medication available to manage any discomfort. Ensure they know that the patient will likely need to be kept asleep to control their symptoms and that involuntary moving or gasping does not reflect suffering if the patient is properly sedated or in a coma.

Explain how the family, clergy and others can be at the bedside before, during and after withdrawal. If asked, explain that they can show love and support through touch, wiping of the patient's forehead, holding a hand and talking to him or her.

Support the decision
Even though a family is able to make a definite decision for ventilator withdrawal, such a decision is always emotionally charged. Families will constantly second-guess themselves, especially if the death appears to linger following ventilator withdrawal. Physician support, guidance and leadership is crucial, as the family will be looking to the physician to ensure them that they are "doing the right thing". Furthermore, it is common for families to have concerns that their decision constitutes euthanasia or assisted suicide-explicit counseling from a physician will be needed. Finally, support needs to continue following death during the bereavement period (see Fast Fact #22).

References: Adapated from: Emanuel, LL, von Gunten, CF, Ferris, FF (eds.). "Module 11: Withholding and Withdrawing Therapy," The EPEC Curriculum: Education for Physicians on End-of-life Care. www.EPEC.net: The EPEC Project, 1999.

Principles and practice of withdrawing life-sustaining treatment in the ICU. Rubenfeld GD and Crawford SW, in Managing death in the Intensive Care Unit. Curtis JR and Rubenfeld GD (eds) Oxford University Press, 2001 pgs. 127-147.

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: von Gunten C and Weissman DE. Fast Facts and Concepts #35: INFORMATION FOR PATIENTS AND FAMILIES ABOUT VENTILATOR WITHDRAWAL; February, 2001. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 2/2001

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)
Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Clergy/Chaplains, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers

ACGME Competencies: Interpersonal and Communication Skills, Patient Care

Keyword(s): Caring for families, Family conference, Negotiating treatment goals, Post-death family care, Treatment withdrawal, Treatment withholding


The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).