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

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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 CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

Withholding, Withdrawing Therapy

Module 11

  • 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

Elective intubation



Blood transfusions, blood products

Diagnostic tests

Artificial nutrition, hydration


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