# 034 Symptom Control for Ventilator Withdrawal in the Dying Patient, 2nd ed

FAST FACTS AND CONCEPTS #034 PDF


Author(s): Charles von Gunten MD, PhD and David E Weissman MD

Introduction This is the second of a three-part series. Fast Fact #33 reviewed a protocol for removing the ventilator, and Fast Fact #35 will review information for families.

The most common symptoms related to ventilator withdrawal are breathlessness and anxiety. Opioids and benzodiazepines are the primary medications used; concerns about unintended hastened death are exaggerated, particularly if established dosing guidelines are followed (see Fast Fact #8). There is no medical or ethical justification for withholding sedating medication when death following ventilator withdrawal is the expected goal. However, increasing doses beyond the levels needed to achieve comfort/sedation, with the intention of hastening death, is euthanasia and is not acceptable/legal medical practice.

Sedation should be provided to all patients, even those who are comatose. The doses needed to control symptoms depend on the neurological status of the patient and presence of drug tolerance (these same drugs are commonly used in routine ICU care). In all cases, a senior-level physician should remain at the bedside prior to and immediately following extubation until adequate symptom control is assured.

Medication Protocol

  1. Discontinue paralytics; do not use paralytic agents for ventilator withdrawal.
  2. Administer an IV bolus dose and begin an IV continuous infusion of sedating medication (see below). Do not rely on subcutaneous or enteral drug administration as these take longer to work. For children, obtain dosing advice from a pharmacist or pediatric intensivist.
  3. Titrate drugs to control labored respirations and achieve the desired state of sedation prior to extubation. Testing the eyelid reflex is a common method of quickly assessing level of consciousness.
  4. Have additional medication drawn up and ready to administer at the bedside if needed.
  5. After ventilator withdrawal: If distress ensues immediate symptom control is needed. Use additional sedating medication (e.g. morphine 5-10 mg IV push q 10 min, and/or midazolam, 2-4 mg IV push q 10 min, until distress is relieved). Adjust infusion rates to maintain relief.
  6. Specific dosages are less important than the goal of symptom relief. A goal should be to keep the respiratory rate < 30 and eliminate grimacing and agitation.

NOTE: The following regimens are commonly used; all require a bolus dose followed by a continuous infusion. Dose ranges are approximations and depend in part on patients’ prior exposure to opioids and benzodiazepines. Clinicians should use clinical judgment when deciding on what specific drugs and doses to use. Many institutions have policy and clinical guidelines about the use of opioids and sedatives in these circumstances. Clinicians unfamiliar with the use of these agents in the setting of ventilator withdrawal are urged to consult with an anesthesiologist, critical care specialist, or pain/palliative specialist prior to use.

Regimen A: Morphine plus Midazolam (Adult doses)

  • Good for comatose patients or patients with limited consciousness and/or patients with little prior exposure to these drugs (and thus less risk of tolerance).
  • Bolus: Morphine 2-10 mg; Midazolam 1-2 mg
  • Infusion: Morphine 50% of the bolus dose in mg/hr; Midazolam 1 mg/hr

Regimen B: Pentobarbital (Adult doses)

  • Good for the awake patient who can be expected to have respiratory distress following ventilator withdrawal.
  • Bolus: 1-2 mg/kg (at rate of 50 mg/min)
  • Infusion: 1-2 mg/kg/hr

Regimen C: Propofol (Adult doses)

  • Good for the awake patient who can be expected to have demonstrable respiratory distress following ventilator withdrawal.
  • Bolus: 20-50 mg
  • Infusion: 10-100 mg/hr

References

  1. Rousseau PC. Palliative Sedation. Am J Hosp Pall Care. 2002; 19:295-297.
  2. Truog RD. Barbiturates in the care of the terminally ill. NEJM. 1992; 327:1678-1681.
  3. Chan JD, et al. Narcotic and benzodiazepine use after withdrawal of life support: Association with time to death? Chest. 2004; 126:286-293.
  4. Adapted 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. Chicago, IL: The EPEC Project; 1999. http://www.EPEC.net.
  5. Rubenfeld GD, Crawford SW. Principles and practice of withdrawing life-sustaining treatment in the ICU. In Managing Death in the Intensive Care Unit. Curtis JR and Rubenfeld GD, eds. New York, NY: Oxford University Press; 2001: pp127-147.

Fast Facts and Concepts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published July 2005. Current version re-copy-edited March 2009.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Von Gunten CF, Weissman DE. Symptom Control for Ventilator Withdrawal in the Dying Patient, 2nd Edition. Fast Facts and Concepts. July 2005; 34. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_034.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a 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.

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): ICU