What are the guidelines for compassionate withdrawal of mechanical ventilation?

Guidelines for Compassionate Withdrawal of Mechanical Ventilation

The paramount goal is patient comfort through aggressive symptom management with opioids and benzodiazepines, with mechanical ventilation withdrawn as quickly as comfort allows, typically via terminal extubation to room air. 1

Pre-Withdrawal Preparation

Neuromuscular Blockade Management

• Immediately discontinue all neuromuscular blocking agents and allow complete reversal before proceeding with any withdrawal steps. 1, 2 This is non-negotiable—never extubate or wean a pharmacologically paralyzed patient. 1

Patient Assessment

• Assess responsiveness using verbal and tactile stimuli to establish baseline mental status. 1
• Evaluate for delirium using validated tools (CAM-ICU or ICDSC) when appropriate. 1
• Establish baseline comfort parameters before initiating withdrawal. 2

Family Communication

• Inform families that predicting time to death is impossible and prepare them explicitly for what they will witness (breathing patterns, secretions, color changes). 1, 2 This prevents distress from normal dying phenomena.
• Discuss not only what will be discontinued but emphasize what will be continued for comfort. 1
• Facilitate individualized rituals: music, prayers, spiritual ceremonies, grooming, final meaningful activities. 1
• Establish consensus on timing, method, and who will be present. 1

Pharmaceutical Management Protocol

Opioid Administration (First-Line)

• Treat pain and respiratory distress with opioids BEFORE sedatives. 1 This is the correct sequence.
• Give anticipatory bolus doses of opioids before withdrawal begins, not just reactively. 1, 2

For opioid-naïve patients:

• Administer IV bolus followed by continuous infusion. 1

For patients already on fentanyl infusion:

• Give bolus equal to hourly infusion rate every 5 minutes as needed for breakthrough symptoms. 1
• If patient requires 2 boluses within one hour, double the infusion rate. 1

Sedative Administration (Second-Line)

• Use sedatives only after pain and dyspnea are controlled with opioids. 1
• Combinations of opioids and benzodiazepines are acceptable. 1
• There is no dose limit—titrate to symptoms without ceiling. 1

For benzodiazepine-naïve patients:

• Start with 2 mg IV midazolam bolus, followed by 1 mg/hour infusion. 1
• Adjust based on size, age, and organ dysfunction. 1

For patients on midazolam infusion:

• Give bolus of 1-2× the hourly infusion rate every 5 minutes for breakthrough agitation. 1
• If 2 boluses needed within one hour, double the infusion rate. 1

Alternative sedative:

• Propofol can substitute for benzodiazepines if clinician is experienced with its use during withdrawal. 1

Adjunctive Medications

• Order antiemetics PRN with opioids. 1
• Use inhaled epinephrine for post-extubation stridor in conscious patients. 1
• No routine use of anticholinergics for secretions, furosemide for CHF prevention, or methylprednisolone for stridor prevention. 1

Documentation Requirements

• Document the specific indication for every medication dose (e.g., "for accessory muscle use," "for respiratory rate >30"). 1

Discontinuation of Non-Comfort Interventions

Discontinue all of the following before or concurrent with ventilator withdrawal: 1

• All non-comfort medications
• Blood transfusions
• Hemodialysis
• Vasopressors and inotropes (discontinue these first, before ventilator) 1
• Parenteral and enteral nutrition
• Antibiotics
• IV fluids (particularly important as they cause respiratory congestion and gurgling) 1
• Blood work and laboratory monitoring
• All non-comfort-oriented monitoring (telemetry, pulse oximetry, blood pressure cuffs) 1

Supplemental oxygen: Provide only if needed for comfort, not routinely. 1

Technical Withdrawal Process

Method Selection

Two acceptable approaches exist—choose based on patient/family preference: 1

1. Terminal extubation (immediate removal of endotracheal tube)
2. Terminal weaning (gradual reduction of FiO2 and/or ventilator rate)

Terminal weaning may be preferable when: 1

• Concern exists about noisy breathing from airway secretions disturbing the family
• Gradual approach aligns better with family wishes

Recommended Approach

• In most cases, extubate directly to room air. 1
• Withdraw mechanical ventilation as quickly as comfort allows. 1 Speed is determined by time needed to achieve comfort at each step.
• Do not routinely extubate to non-invasive ventilation. 1
• Extubation is preferable to leaving the patient intubated on minimal support, but either is acceptable. 1

Stepwise Sequence

1. Discontinue vasopressors/inotropes first 1
2. Withdraw mechanical ventilation 1
3. Remove artificial airway 1
4. Ensure symptom control at each step before proceeding 1

Post-Withdrawal Monitoring and Care

Symptom Assessment

• Vigilantly and continuously assess for signs of dyspnea, pain, and agitation after withdrawal. 1
• Use objective assessment tools like the Respiratory Distress Observation Scale. 3
• Respiratory distress occurs in approximately 64% of patients post-withdrawal. 4

Medication Titration

• Continue aggressive titration of opioids and benzodiazepines to maintain comfort—no dose limits. 1
• Administer medications within 30 minutes of identifying distress. 4

Location of Care

• Patients may need to remain in ICU if close symptom monitoring is required. 1
• Transfer to alternative settings is acceptable if palliative needs can be met there. 1
• Consider continuity of caregivers and family familiarity with location. 1

Protocol Development

Each ICU should develop and utilize standardized protocols for withdrawal. 1 Research demonstrates that nurse-led algorithmic approaches improve patient comfort and reduce post-extubation complications like stridor. 3

Critical Pitfalls to Avoid

• Never proceed while neuromuscular blockade is active—this is the most critical error. 1, 2
• Do not withhold adequate opioid/benzodiazepine doses due to fear of hastening death—symptom control is the priority. 2
• Do not use specific respiratory rate thresholds (e.g., >35/min) as sole indicators of distress—use comprehensive assessment. 1
• Do not surprise families with normal dying phenomena—prepare them in advance. 2
• Do not provide supplemental oxygen routinely—only for comfort. 1

Team Composition

Optimal team presence during withdrawal includes: 4

• Registered nurse (100% of cases)
• Attending physician (100% of cases)
• Respiratory therapist (80% of cases)
• Chaplain/spiritual care (as desired by family)