What is the appropriate protocol for withdrawing ventilator support from a patient with acute respiratory failure who has expressed a desire not to be kept alive on a ventilator (ventilator)?

Withdrawal of Ventilator Support in a Patient with Expressed Wishes Against Mechanical Ventilation

When a patient with acute respiratory failure has previously expressed wishes not to be kept alive on a ventilator (as reported by adult children), the ventilator should be withdrawn in accordance with the patient's wishes, using a protocol that prioritizes symptom management and family support.

Confirming Patient Wishes

• Verify the patient's previously expressed wishes with both adult children to ensure accurate understanding of the patient's preferences 1
• Document the conversation with family members in the medical record
• If available, review any advance directives or living wills that may provide additional guidance 2

Pre-Withdrawal Preparation

1. Team Communication:

   • Establish consensus among healthcare team members about the withdrawal process 1
   • Consult palliative care services for assistance with symptom management 2
   • Clarify with staff the ethical distinction between withdrawal of treatment (which is legal) and euthanasia 1

2. Family Preparation:

   • Explain the withdrawal process to family members, including:
     • What to expect during the dying process
     • That timing of death after withdrawal is unpredictable
     • The medications that will be used for comfort
   • Offer family members the opportunity to be present during the process 1
   • Assign a team member to remain with the family to answer questions and provide support 1

3. Medication Preparation:

   • Prepare anticipatory medications before beginning withdrawal:
     • Opioids (e.g., morphine 2.5-10 mg IV every 4 hours PRN) for dyspnea 2
     • Benzodiazepines (e.g., lorazepam 0.5-1 mg IV every 4 hours PRN) for anxiety 2
     • Anticholinergics (e.g., glycopyrrolate) for secretion management 1
     • Ensure any neuromuscular blockade has completely worn off 1

Withdrawal Process

1. Discontinue Non-Comfort Monitoring:

   • Remove unnecessary monitoring equipment 1
   • Focus on clinical assessment of comfort

2. Choose Withdrawal Method:

   • Terminal extubation: complete removal of the endotracheal tube
   • Terminal weaning: gradual reduction of ventilator support 2, 1
   • For most patients with acute respiratory failure, a rapid terminal wean is preferred to allow for medication titration 1

3. Implement Withdrawal:

   • Administer pre-withdrawal doses of opioids and benzodiazepines 2, 1
   • Reduce FiO2 to room air
   • Reduce PEEP to zero
   • Reduce ventilator rate or change to pressure support mode
   • Complete extubation or disconnect from ventilator
   • The responsible physician should personally conduct and accompany the implementation 2

4. Symptom Management During and After Withdrawal:

   • Continuously assess for signs of dyspnea, pain, or anxiety
   • Titrate opioids and benzodiazepines to maintain comfort 2, 1
   • Administer anticholinergics if noisy breathing ("death rattle") develops 1
   • Consider discontinuing IV fluids if fluid overload is contributing to respiratory distress 2

Family Support During and After Death

• Provide emotional and spiritual support to family members 1
• Offer grief counseling resources
• Consider sending a condolence letter with bereavement support information 1

Common Pitfalls and How to Avoid Them

1. Legal/Ethical Confusion:

   • Some healthcare professionals may confuse withdrawal of treatment with euthanasia
   • Clarify that withdrawal allows the natural disease process to unfold without technological intervention 1
   • Emphasize that the intent is not to hasten death but to respect patient autonomy

2. Inadequate Symptom Management:

   • Undertreatment of dyspnea and anxiety is common
   • Use appropriate doses of opioids and benzodiazepines without fear of respiratory depression, as the goal is comfort 2, 1
   • Monitor closely and titrate medications as needed

3. Poor Communication:

   • Failure to prepare family for what to expect
   • Provide clear information about the expected process and appearance of the patient
   • Ensure family understands that predicting time to death is difficult 1

By following this protocol, healthcare providers can honor the patient's wishes while ensuring comfort and dignity during the withdrawal process, and providing appropriate support to family members.