The project to educate physicians on end of life care supported by the american medical association and the robert wood johnson foundation
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The Project to Educate Physicians on End-of-life Care Supported by the American Medical Association and the Robert Wood Johnson Foundation. Withholding, Withdrawing Therapy. Module 11. Objectives. Know the principles for withholding or withdrawing therapy

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The Project to Educate Physicians on End-of-life Care Supported by the American Medical Association and the Robert Wood Johnson Foundation

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The project to educate physicians on end of life care supported by the american medical association and the robert wood johnson foundation

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

Withholding, Withdrawing Therapy

Module 11


Objectives

Objectives

  • Know the principles for withholding or withdrawing therapy

  • Apply these principles to the withholding or withdrawal of

    • artificial feeding, hydration

    • ventilation

    • cardiopulmonary resuscitation


Role of the physician

Role of the physician . . .

  • The physician helps the patient and family

    • elucidate their own values

    • decide about life-sustaining treatments

    • dispel misconceptions

  • Understand goals of care

  • Facilitate decisions, reassess regularly


  • Role of the physician1

    . . . Role of the physician

    • Discuss alternatives

      • including palliative and hospice care

    • Document preferences, medical orders

    • Involve, inform other team members

    • Assure comfort, nonabandonment


    Common concerns

    Common concerns . . .

    • Legally required to “do everything?”

    • Is withdrawal, withholding euthanasia?

    • Are you killing the patient when you remove a ventilator or treat pain?


    Common concerns1

    . . . Common concerns

    • Can the treatment of symptoms constitute euthanasia?

    • Is the use of substantial doses of opioids euthanasia?


    Life sustaining treatments

    Resuscitation

    Elective intubation

    Surgery

    Dialysis

    Blood transfusions, blood products

    Diagnostic tests

    Artificial nutrition, hydration

    Antibiotics

    Other treatments

    Future hospital, ICU admissions

    Life-sustaining treatments


    8 step protocol to discuss treatment preferences

    8-step protocol to discuss treatment preferences . . .

    1. Be familiar with policies, statutes

    2. Appropriate setting for the discussion

    3. Ask the patient, family what they understand

    4. Discuss general goals of care


    8 step protocol to discuss treatment preferences1

    . . . 8-step protocol to discuss treatment preferences

    5. Establish context for the discussion

    6. Discuss specific treatment preferences

    7. Respond to emotions

    8. Establish and implement the plan


    Aspects of informed consent

    Aspects of informed consent

    • Problem treatment would address

    • What is involved in the treatment / procedure

    • What is likely to happen if the patient decides not to have the treatment

    • Treatment benefits

    • Treatment burdens


    Example 1 artifical feeding hydration

    Example 1: Artifical feeding, hydration

    • Difficult to discuss

    • Food, water are symbols of caring


    Review goals of care

    Review goals of care

    • Establish overall goals of care

    • Will artificial feeding, hydration help achieve these goals?


    Address misperceptions

    Address misperceptions

    • Cause of poor appetite, fatigue

    • Relief of dry mouth

    • Delirium

    • Urine output


    Help family with need to give care

    Help family with need to give care

    • Identify feelings, emotional needs

    • Identify other ways to demonstrate caring

      • teach the skills they need


    Normal dying

    Normal dying

    • Loss of appetite

    • Decreased oral fluid intake

    • Artificial food / fluids may make situation worse

      • breathlessness

      • edema

      • ascites

      • nausea / vomiting


    Example 2 ventilator withdrawal

    Example 2: Ventilator withdrawal

    • Rare, challenging

    • Ask for assistance

    • Assess appropriateness of request

    • Role in achieving overall goals of care


    Immediate extubation

    Immediate extubation

    • Remove the endotracheal tube after appropriate suctioning

    • Give humidified air or oxygen to prevent the airway from drying

    • Ethically sound practice


    Terminal weaning

    Terminal weaning

    • Rate, PEEP, oxygen levels are decreased first

    • Over 30–60 minutes or longer

    • A Briggs T piece may be used in place of the ventilator

    • Patients may then be extubated


    Ensure patient comfort

    Ensure patient comfort

    • Anticipate and prevent discomfort

    • Have anxiolytics, opioids immediately available

    • Titrate rapidly to comfort

    • Be present to assess, reevaluate


    Prevent symptoms

    Prevent symptoms

    • Breathlessness

      • opioids

    • Anxiety

      • benzodiazepines


    Preparing for ventilator withdrawal

    Preparing for ventilator withdrawal

    • Determine degree of desired consciousness

    • Bolus 2-20 mg morphine IV, then continuous infusion

    • Bolus 1-2 mg midazolam IV, then continuous infusion

    • Titrate to degree of consciousness, comfort


    Prepare the family

    Prepare the family . . .

    • Describe the procedure

    • Reassure that comfort is a primary concern

    • Medication is available

    • Patient may need to sleep to be comfortable


    Prepare the family1

    . . . Prepare the family

    • Involuntary movements

    • Provide love and support

    • Describe uncertainty


    Prior to withdrawal

    Prior to withdrawal

    • Prior to procedure

      • discussion and agreement to discontinue

        • with patient (if conscious)

        • with family, nurses, respiratory therapists

      • document on the patient’s chart


    Withdrawal protocol part 1

    Withdrawal protocol– part 1

    • Procedure

      • shut off alarms

      • remove restraints

      • NG tube is removed

      • family is invited into the room

      • pressors are turned off

      • parents may hold child


    Withdrawal protocol part 2

    Withdrawal protocol–part 2

    • Establish adequate symptom control prior to extubation

    • Have medications IN HAND

      • midazolam, lorazepam, or diazepam

    • Set FiO2 to 21%

    • Adjust medications

    • Remove the ET tube


    Withdrawal protocol part 3

    Withdrawal protocol– part 3 . . .

    • Invite family to bedside

    • Washcloth, oral suction catheter, facial tissues

    • Reassess frequently


    Withdrawal protocol part 31

    . . . Withdrawal protocol– part 3

    • After the patient dies

      • talk with family and staff

      • provide acute grief support

    • Offer bereavement support to family members

      • follow up to ensure they are okay


    Example 3 cardiopulmonary resuscitation

    Example 3: Cardiopulmonary resuscitation

    • Establish general goals of care

    • Use understandable language

    • Avoid implying the impossible

    • Ask about other life-prolonging therapies

    • Affirm what you will be doing


    Write appropriate medical orders

    Write appropriate medical orders

    • DNR

    • DNI

    • Do not transfer

    • Others

    • POLST


    Withholding withdrawing therapy summary

    Withholding, Withdrawing Therapy

    Summary


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