What considerations should be taken during terminal ventilator withdrawal?

Terminal Ventilator Withdrawal: Key Clinical Considerations

Develop an individualized care plan that addresses four critical domains: preparation (patient/family/environment), symptom assessment and management, pharmaceutical protocols, and the technical process of withdrawal itself. 1

Pre-Withdrawal Preparation

Patient Assessment

• Discontinue neuromuscular blockers immediately and allow effects to wear off or be reversed before proceeding 1
• Assess patient responsiveness using verbal and tactile stimuli 1
• Evaluate baseline comfort level and establish monitoring parameters 1

Family Communication and Environment

• Inform families that predicting time to death after withdrawal is difficult and prepare them for what they will witness during the dying process 1
• Educate families about "death rattle" (noisy breathing from secretions, occurring in ~25% of patients) and "agonal breathing" (slow, irregular, grunting respirations) as normal parts of dying, not signs of distress 1
• Reach consensus on timing, method of withdrawal, and who will be present 1
• Create opportunities for meaningful activities: playing music, spiritual ceremonies, grooming, life review, or for pediatric patients—bathing, dressing, holding the child 1
• Emphasize what will be continued (comfort measures) not just what will be discontinued 1

Discontinue Non-Comfort Medications

• Stop antibiotics and other life-prolonging treatments before withdrawal 1
• Discontinue intravenous fluids as they cause respiratory congestion and gurgling 1
• Maintain only medications necessary for symptom control 1

Pharmaceutical Management Protocol

Anticipatory Medication Administration

Administer anticipatory titrated doses of opioids and benzodiazepines BEFORE withdrawal to prevent dyspnea and anxiety 1

Ongoing Symptom Management

• Continuously titrate opioids and benzodiazepines to maintain satisfactory control of distress signs after withdrawal 1
• Use standardized pain scales and objective signs (tachypnea, accessory muscle use, vital sign changes) to assess distress 1
• Monitor vigilantly and frequently for signs of dyspnea and pain 1
• Do NOT increase opioid doses for death rattle or agonal breathing alone—these are not indicators of patient discomfort 1

Management of Death Rattle

• Treat with anticholinergic agents if distressing to family 1
• Eliminate IV fluids to reduce bronchial secretions 1
• Recognize that noisy breathing from intrinsic lung pathology usually resists therapy 1

Technical Withdrawal Methods

Choose Between Two Approaches

Both terminal extubation (immediate tube removal) and terminal weaning (gradual reduction of FiO2/rate) are acceptable; the choice should respect patient/surrogate preferences 1

Terminal Weaning Advantages

• Terminal weaning helps avoid noisy breathing from airway secretions that may disturb families 1
• Some view terminal weaning as controversial; clinicians should be adept at both methods 1

Monitoring Considerations

• Discontinue physiologic monitoring (cardiac monitors, pulse oximetry) as it serves no comfort purpose 1
• A healthcare team member should remain available to patient and family until death 1
• Physicians must personally conduct and accompany the withdrawal process, not delegate entirely to nursing staff 1

Post-Withdrawal Care Location

ICU vs. Alternative Settings

• Patients may need to remain in ICU if close symptom monitoring is required 1
• Transfer to alternative settings is appropriate if palliative needs can be met and ICU bed demand is high 1
• Continuity of caregivers and familiar environment may benefit families 1

Critical Pitfalls to Avoid

• Never proceed with withdrawal while neuromuscular blockade is still active 1
• Do not withhold adequate opioid/benzodiazepine doses due to fear of hastening death—symptom control is the priority 1, 2
• Avoid surprising families with normal dying phenomena (death rattle, agonal breathing) by preparing them in advance 1
• Do not continue IV fluids as they worsen respiratory secretions 1
• Recognize that any life-shortening from necessary symptom control medications should be tolerated as unavoidable side effects 1