Approaching Ventilator Withdrawal

The decision to extubate a patient who is ventilator-dependent is usually difficult. Problems may arise in communication with the patient and/or family, issues of differences in beliefs and culture with regard to life-sustaining treatment, certainty of prognosis, practical issues of location (in the ICU, on a med-surg floor, at home, or referral to a hospice inpatient care center) and care delivery. The following case illustrates some of these.

E.F. is an 89-year-old woman who has been ventilated in an ICU for three months following cardiac surgery. All attempts at ventilator weaning and withdrawal have failed, and recently she developed worsening renal function. When her creatinine reached 5 and she developed anasarca, dialysis was recommended. The patient (who was alert and capable of decision-making) refused dialysis. Instead she requested that she be sent home, extubated, and allowed to die in her own bed.

Her family (daughter, son, grandson) arrived with many questions. They were generally in agreement with her decision but had three different opinions about how long she should be home before extubation (immediate, next day, a “few” days). The patient and all the family members declined extubation in any other setting.

A hospice agency agreed to take on the challenge of getting her home. The initial problem was in locating a ventilator that could be used in the patient’s home — there are few agencies that can supply a ventilator on short notice. Additionally, Medicare regulations prohibit home health or hospice nurses from “managing” a ventilator without being certified. In usual circumstances of home-ventilator care, the family is responsible for the ventilator between visits from a respiratory therapist.

Transportation of the patient from the ICU to another level of care outside the hospital requires critical care transport with a portable ventilator. This unit must leave with the ambulance when the patient is settled (at home, long-term care facility, or hospice inpatient care center). In this patient’s situation, when it looked unlikely a ventilator for home use would be found, immediate extubation after arrival at home was offered to the family and patient. The patient agreed that this was better than staying in the ICU, but some family members were very unhappy with the idea. They wanted to have more time for goodbyes. Finally, a ventilator was located shortly before the patient arrived home on Friday evening. A physician and the respiratory therapist from the rental company instructed the family in ventilator management, and round-the-clock nursing care was instituted to administer medications for comfort. The patient was alert until late the second full day home. The physician returned on the third day, at the family’s request, and the patient died one hour following extubation with her family present.

Approaching the patient and family communication issues depends on the patient’s decision-making capacity and the capacity of both patient and family to communicate. If the patient is alert enough to have decisional capacity, the patient needs to be included in the discussions. Whenever feasible, it is helpful for the patient to be interviewed with the family present so the family is fully aware of the patient’s desires. No matter where the extubation is planned to occur, these things need to be addressed.

1. Begin with inquiry: Does the patient/family and/or decision-maker understand the medical issues and consequences of the choice between continued ventilatory support and withdrawal of the ventilator? Are the patient’s overall goals of care known, and is extubation consistent with these goals? If the patient is alert, does he or she have a preference about level of sedation after extubation (alert carries more risk of dyspnea; asleep is unable to communicate). Ascertain that the patient is DNR.
2. Explain how and what medications will be used to prevent anxiety and dyspnea.
3. Confirm that death may or may not be immediate.
4. Reassure the patient and family that extubation is ethical as withdrawal of unwanted therapy.
5. Ascertain which other issues exist for the patient:
   • Is there another symptom to treat (such as nausea, pain)?
   • Does the patient have questions, fears, or other unmet security issues?
   • Is everyone whom the patient wants present able to be present? Is time needed for travel?
   • Is everyone being treated with respect and dignity? Does the patient desire grooming?
   • Are spiritual and existential issues addressed? Are there religious rites to be observed (such as anointing of the sick for Catholic patients)?
   • Are final arrangements (mortuary, cremation, or burial) in place?

Approaching delivery of care requires coordination. We would suggest putting one individual in charge with a checklist, especially for an extubation at home.

1. Arrange critical care transport.
2. Arrange in-home ventilator and respiratory therapist to arrive before patient.
3. Arrange medication to be present before patient (opioid plus sedative, such as a benzodiazepine for IV or subcutaneous administration). Glycopyrrolate for excessive secretions may be helpful as well.
4. Arrange for suction equipment to be available.
5. Arrange for nursing care for medications and assessment.
6. Arrange for physician home visit to titrate medication.
7. Arrange for family to be present.
8. Arrange for pastoral care if part of the plan of care.

To extubate in a facility, the same issues should be addressed but may be done without the travel component: respiratory therapy or trained nurse, available medication and physician, and presence of family and pastoral care.

When preparing to extubate, reconfirm the patient/decision-maker goal to withdraw ventilatory support and that the patient continues to elect DNR. Determine that the patient has those present who can and wish to be there. Begin a line for IV (or subcutaneous access) if implanted line not present. Allow pastoral care. Administer small dose of opioid. Administer the benzodiazepine if patient has desired sedation or is anxious. Wean ventilator and extubate. Clean face (if ET tube) and allow family to be with patient. Titrate the opioid for dyspnea and the benzodiazepine for anxiety until the desired level of sedation is reached. Continue to dose these medications only as necessary to maintain patient comfort. It is not the goal to hasten death.

These issues can become even more difficult if there is disagreement between physician and patient/family about ventilator withdrawal. When the patient and family want to withdraw, the physician usually must comply or transfer the patient unless he/she can prove the request is irrational and does not take into account the consequences. When the physician requests the withdrawal because the intervention is “futile” and the patient/family refuses (generally this is family because in futile situations the patient is usually unresponsive), much more conversation is necessary. While it is said that the physician is not obligated to provide futile care, it is clearly a better outcome if reluctant families can be given the time, support, and information to come to agreement with the physician.