Fast Fact and Concept #034: Symptom Control for Ventilator Withdrawal in the Dying Patient (Part II)

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

Note: This is Part II of a three-part series; Part I reviewed a protocol for removing the ventilator (FF #33), Part III (FF #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 to provide comfort, typically requiring doses that cause sedation, to achieve good symptom control. Concerns about unintended secondary effects, such as shortened life, are exaggerated, particularly if established dosing guidelines are followed (see Fast Fact #8). There is no medical, ethical or legal justification for withholding sedating medication, when death following ventilator withdrawal is the expected goal, out of fear of hastening death. 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 dose needed to control symptoms will depends to some degree on the neurological status of the patient and the amount of similar medication used up to the time of extubation. Patients who are awake at the time of extubation or in whom significant amounts of opioids and benzodiazepines have been used previously, will require greater dosages or change to a barbiturate to achieve symptom control. Note: 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. Before ventilator withdrawal: Administer a bolus dose of morphine 2-10 mg IV and start a continuous morphine infusion at 50% of the bolus dose/h. Also, administer 1 to 2 mg of midazolam IV (or Lorazepam).and begin a midazolam infusion at 1 mg/h. Note: Sedation should also be administered to the comatose patient. For children, obtain dosing advice from a pharmacist or pediatric intensivist.
3. Titrate these drugs to minimize anxiety and achieve the desired state of comfort and sedation prior to extubation.
4. Have additional medication drawn up and ready to administer at the bedside so it can be rapidly administered, if needed to provide symptom relief.

5. After ventilator withdrawal: If distress ensues aggressive and immediate symptom control is needed. Use morphine 5 to 10 mg IV push q 10 min, and/or midazolam, 2 to 4 mg IV push q 10 min, until distress is relieved. Adjust both infusion rates to maintain relief.
6. Remember that specific dosages are less important than the goal of symptom relief. A general goal should be to keep the respiratory rate < 30, heart rate < 100 and eliminate grimacing and agitation.
7. For symptoms refractory to the above treatments, use a barbiturate (e.g. pentobarbital), haloperidol or propofol.

References
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.{ HYPERLINK "http://www.EPEC.net" }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.

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Please e-mail suggested future topics for Fast Facts; Let us know how you used this material-send an e-mail describing the educational format and the learner reaction. Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339- 340.

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 #34: SYMPTOM CONTROL FOR VENTILATOR WITHDRAWAL IN THE DYING PATIENT; February, 2001. End-of- Life Physician Education Resource Center www.eperc.mcw.edu.

Need peer-reviewed information about Physician End-of-Life Educational material or resources??? Visit the End-of-Life Physician Education Resource Center (EPERC) at www.eperc.mcw.edu

David E. Weissman, MD, FACP Editor, Journal of Palliative Medicine Palliative Care Program Director Medical College of Wisconsin (P) 414-805-4607 (F) 414-805-4608

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: 2/2000

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): ICU

Specific Disease and Organ System Category(s): ICU