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EEPPEECC
EEPPEECC
Withholding, Withdrawing Therapy
Withholding, Withdrawing Therapy
Module 11Module 11Module 11Module 11
The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation
The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation
ObjectivesObjectives
Know the principles for withholding Know the principles for withholding or withdrawing therapyor withdrawing therapy
Apply these principles to the Apply these principles to the withholding or withdrawal ofwithholding or withdrawal of
artificial feeding, hydrationartificial feeding, hydration
ventilationventilation
cardiopulmonary resuscitationcardiopulmonary resuscitation
Know the principles for withholding Know the principles for withholding or withdrawing therapyor withdrawing therapy
Apply these principles to the Apply these principles to the withholding or withdrawal ofwithholding or withdrawal of
artificial feeding, hydrationartificial feeding, hydration
ventilationventilation
cardiopulmonary resuscitationcardiopulmonary resuscitation
Role of the physician . . .Role of the physician . . .
The physician helps the patient and The physician helps the patient and family family
elucidate their own valueselucidate their own values
decide about life-sustaining decide about life-sustaining treatmentstreatments
dispel misconceptionsdispel misconceptions
Understand goals of careUnderstand goals of care
Facilitate decisions, reassess Facilitate decisions, reassess regularlyregularly
The physician helps the patient and The physician helps the patient and family family
elucidate their own valueselucidate their own values
decide about life-sustaining decide about life-sustaining treatmentstreatments
dispel misconceptionsdispel misconceptions
Understand goals of careUnderstand goals of care
Facilitate decisions, reassess Facilitate decisions, reassess regularlyregularly
. . . Role of the physician. . . Role of the physician
Discuss alternativesDiscuss alternatives
including palliative and hospice careincluding palliative and hospice care
Document preferences, medical Document preferences, medical ordersorders
Involve, inform other team membersInvolve, inform other team members
Assure comfort, nonabandonmentAssure comfort, nonabandonment
Discuss alternativesDiscuss alternatives
including palliative and hospice careincluding palliative and hospice care
Document preferences, medical Document preferences, medical ordersorders
Involve, inform other team membersInvolve, inform other team members
Assure comfort, nonabandonmentAssure comfort, nonabandonment
Common concerns . . .Common concerns . . .
Legally required to “do everything?”Legally required to “do everything?”
Is withdrawal, withholding Is withdrawal, withholding euthanasia?euthanasia?
Are you killing the patient when you Are you killing the patient when you remove a ventilator or treat pain?remove a ventilator or treat pain?
Legally required to “do everything?”Legally required to “do everything?”
Is withdrawal, withholding Is withdrawal, withholding euthanasia?euthanasia?
Are you killing the patient when you Are you killing the patient when you remove a ventilator or treat pain?remove a ventilator or treat pain?
. . . Common concerns. . . Common concerns
Can the treatment of symptoms Can the treatment of symptoms constitute euthanasia?constitute euthanasia?
Is the use of substantial doses of Is the use of substantial doses of opioids euthanasia?opioids euthanasia?
Can the treatment of symptoms Can the treatment of symptoms constitute euthanasia?constitute euthanasia?
Is the use of substantial doses of Is the use of substantial doses of opioids euthanasia?opioids euthanasia?
Life-sustaining treatmentsLife-sustaining treatments ResuscitationResuscitation
Elective intubationElective intubation
SurgerySurgery
DialysisDialysis
Blood Blood transfusions, transfusions, blood productsblood products
ResuscitationResuscitation
Elective intubationElective intubation
SurgerySurgery
DialysisDialysis
Blood Blood transfusions, transfusions, blood productsblood products
Diagnostic testsDiagnostic tests
Artificial nutrition, Artificial nutrition, hydrationhydration
AntibioticsAntibiotics
Other treatmentsOther treatments
Future hospital, Future hospital, ICU admissionsICU admissions
Diagnostic testsDiagnostic tests
Artificial nutrition, Artificial nutrition, hydrationhydration
AntibioticsAntibiotics
Other treatmentsOther treatments
Future hospital, Future hospital, ICU admissionsICU admissions
8-step protocol to discuss treatment preferences . . .8-step protocol to discuss treatment preferences . . .
1.1. Be familiar with policies, statutes Be familiar with policies, statutes
2.2. Appropriate setting for the Appropriate setting for the discussiondiscussion
3.3. Ask the patient, family what they Ask the patient, family what they understandunderstand
4.4. Discuss general goals of care Discuss general goals of care
1.1. Be familiar with policies, statutes Be familiar with policies, statutes
2.2. Appropriate setting for the Appropriate setting for the discussiondiscussion
3.3. Ask the patient, family what they Ask the patient, family what they understandunderstand
4.4. Discuss general goals of care Discuss general goals of care
. . . 8-step protocol to discuss treatment preferences
. . . 8-step protocol to discuss treatment preferences5.5. Establish context for the discussion Establish context for the discussion
6.6. Discuss specific treatment Discuss specific treatment preferencespreferences
7.7. Respond to emotions Respond to emotions
8.8. Establish and implement the plan Establish and implement the plan
5.5. Establish context for the discussion Establish context for the discussion
6.6. Discuss specific treatment Discuss specific treatment preferencespreferences
7.7. Respond to emotions Respond to emotions
8.8. Establish and implement the plan Establish and implement the plan
Aspects of informed consentAspects of informed consent Problem treatment would addressProblem treatment would address
What is involved in the treatment / What is involved in the treatment / procedureprocedure
What is likely to happen if the patient What is likely to happen if the patient decides not to have the treatmentdecides not to have the treatment
Treatment benefitsTreatment benefits
Treatment burdensTreatment burdens
Problem treatment would addressProblem treatment would address
What is involved in the treatment / What is involved in the treatment / procedureprocedure
What is likely to happen if the patient What is likely to happen if the patient decides not to have the treatmentdecides not to have the treatment
Treatment benefitsTreatment benefits
Treatment burdensTreatment burdens
Example 1: Artifical feeding, hydrationExample 1: Artifical feeding, hydration Difficult to discussDifficult to discuss
Food, water are symbols of caring Food, water are symbols of caring
Difficult to discussDifficult to discuss
Food, water are symbols of caring Food, water are symbols of caring
Review goals of careReview goals of care
Establish overall goals of careEstablish overall goals of care
Will artificial feeding, hydration help Will artificial feeding, hydration help achieve these goals?achieve these goals?
Establish overall goals of careEstablish overall goals of care
Will artificial feeding, hydration help Will artificial feeding, hydration help achieve these goals?achieve these goals?
Address misperceptionsAddress misperceptions
Cause of poor appetite, fatigueCause of poor appetite, fatigue
Relief of dry mouthRelief of dry mouth
DeliriumDelirium
Urine outputUrine output
Cause of poor appetite, fatigueCause of poor appetite, fatigue
Relief of dry mouthRelief of dry mouth
DeliriumDelirium
Urine outputUrine output
Help family with need to give careHelp family with need to give care Identify feelings, emotional needsIdentify feelings, emotional needs
Identify other ways to demonstrate Identify other ways to demonstrate caringcaring
teach the skills they needteach the skills they need
Identify feelings, emotional needsIdentify feelings, emotional needs
Identify other ways to demonstrate Identify other ways to demonstrate caringcaring
teach the skills they needteach the skills they need
Normal dyingNormal dying Loss of appetiteLoss of appetite
Decreased oral fluid intakeDecreased oral fluid intake
Artificial food / fluids may make Artificial food / fluids may make situation worsesituation worse
breathlessnessbreathlessness
edemaedema
ascitesascites
nausea / vomitingnausea / vomiting
Loss of appetiteLoss of appetite
Decreased oral fluid intakeDecreased oral fluid intake
Artificial food / fluids may make Artificial food / fluids may make situation worsesituation worse
breathlessnessbreathlessness
edemaedema
ascitesascites
nausea / vomitingnausea / vomiting
Example 2: Ventilator withdrawalExample 2: Ventilator withdrawal Rare, challengingRare, challenging
Ask for assistanceAsk for assistance
Assess appropriateness of requestAssess appropriateness of request
Role in achieving overall goals of Role in achieving overall goals of carecare
Rare, challengingRare, challenging
Ask for assistanceAsk for assistance
Assess appropriateness of requestAssess appropriateness of request
Role in achieving overall goals of Role in achieving overall goals of carecare
Immediate extubationImmediate extubation
Remove the endotracheal tube after Remove the endotracheal tube after appropriate suctioningappropriate suctioning
Give humidified air or oxygen to Give humidified air or oxygen to prevent the airway from dryingprevent the airway from drying
Ethically sound practiceEthically sound practice
Remove the endotracheal tube after Remove the endotracheal tube after appropriate suctioningappropriate suctioning
Give humidified air or oxygen to Give humidified air or oxygen to prevent the airway from dryingprevent the airway from drying
Ethically sound practiceEthically sound practice
Terminal weaningTerminal weaning
Rate, PEEP, oxygen levels are Rate, PEEP, oxygen levels are decreased firstdecreased first
Over 30–60 minutes or longerOver 30–60 minutes or longer
A Briggs T piece may be used in A Briggs T piece may be used in place of the ventilatorplace of the ventilator
Patients may then be extubatedPatients may then be extubated
Rate, PEEP, oxygen levels are Rate, PEEP, oxygen levels are decreased firstdecreased first
Over 30–60 minutes or longerOver 30–60 minutes or longer
A Briggs T piece may be used in A Briggs T piece may be used in place of the ventilatorplace of the ventilator
Patients may then be extubatedPatients may then be extubated
Ensure patient comfortEnsure patient comfort
Anticipate and prevent discomfortAnticipate and prevent discomfort
Have anxiolytics, opioids Have anxiolytics, opioids immediately availableimmediately available
Titrate rapidly to comfortTitrate rapidly to comfort
Be present to assess, reevaluateBe present to assess, reevaluate
Anticipate and prevent discomfortAnticipate and prevent discomfort
Have anxiolytics, opioids Have anxiolytics, opioids immediately availableimmediately available
Titrate rapidly to comfortTitrate rapidly to comfort
Be present to assess, reevaluateBe present to assess, reevaluate
Prevent symptomsPrevent symptoms
BreathlessnessBreathlessness
opioidsopioids
AnxietyAnxiety
benzodiazepinesbenzodiazepines
BreathlessnessBreathlessness
opioidsopioids
AnxietyAnxiety
benzodiazepinesbenzodiazepines
Preparing for ventilator withdrawalPreparing for ventilator withdrawal Determine degree of desired Determine degree of desired
consciousnessconsciousness
Bolus 2-20 mg morphine IV, then Bolus 2-20 mg morphine IV, then continuous infusioncontinuous infusion
Bolus 1-2 mg midazolam IV, then Bolus 1-2 mg midazolam IV, then continuous infusioncontinuous infusion
Titrate to degree of consciousness, Titrate to degree of consciousness, comfortcomfort
Determine degree of desired Determine degree of desired consciousnessconsciousness
Bolus 2-20 mg morphine IV, then Bolus 2-20 mg morphine IV, then continuous infusioncontinuous infusion
Bolus 1-2 mg midazolam IV, then Bolus 1-2 mg midazolam IV, then continuous infusioncontinuous infusion
Titrate to degree of consciousness, Titrate to degree of consciousness, comfortcomfort
Prepare the family . . .Prepare the family . . .
Describe the procedureDescribe the procedure
Reassure that comfort is a primary Reassure that comfort is a primary concernconcern
Medication is availableMedication is available
Patient may need to sleep to be Patient may need to sleep to be comfortablecomfortable
Describe the procedureDescribe the procedure
Reassure that comfort is a primary Reassure that comfort is a primary concernconcern
Medication is availableMedication is available
Patient may need to sleep to be Patient may need to sleep to be comfortablecomfortable
. . . Prepare the family. . . Prepare the family
Involuntary movementsInvoluntary movements
Provide love and supportProvide love and support
Describe uncertaintyDescribe uncertainty
Involuntary movementsInvoluntary movements
Provide love and supportProvide love and support
Describe uncertaintyDescribe uncertainty
Prior to withdrawalPrior to withdrawal
Prior to procedurePrior to procedure
discussion and agreement to discussion and agreement to discontinue discontinue
with patient (if conscious)with patient (if conscious)
with family, nurses, respiratory with family, nurses, respiratory therapiststherapists
document on the patient’s chartdocument on the patient’s chart
Prior to procedurePrior to procedure
discussion and agreement to discussion and agreement to discontinue discontinue
with patient (if conscious)with patient (if conscious)
with family, nurses, respiratory with family, nurses, respiratory therapiststherapists
document on the patient’s chartdocument on the patient’s chart
Withdrawal protocol– part 1Withdrawal protocol– part 1 ProcedureProcedure
shut off alarmsshut off alarms
remove restraints remove restraints
NG tube is removed NG tube is removed
family is invited into the roomfamily is invited into the room
pressors are turned offpressors are turned off
parents may hold childparents may hold child
ProcedureProcedure
shut off alarmsshut off alarms
remove restraints remove restraints
NG tube is removed NG tube is removed
family is invited into the roomfamily is invited into the room
pressors are turned offpressors are turned off
parents may hold childparents may hold child
Withdrawal protocol–part 2Withdrawal protocol–part 2 Establish adequate symptom control Establish adequate symptom control
prior to extubationprior to extubation
Have medications IN HAND Have medications IN HAND
midazolam, lorazepam, or diazepam midazolam, lorazepam, or diazepam
Set FiOSet FiO22 to 21% to 21%
Adjust medications Adjust medications
Remove the ET tubeRemove the ET tube
Establish adequate symptom control Establish adequate symptom control prior to extubationprior to extubation
Have medications IN HAND Have medications IN HAND
midazolam, lorazepam, or diazepam midazolam, lorazepam, or diazepam
Set FiOSet FiO22 to 21% to 21%
Adjust medications Adjust medications
Remove the ET tubeRemove the ET tube
Withdrawal protocol– part 3 . . .Withdrawal protocol– part 3 . . . Invite family to bedsideInvite family to bedside
Washcloth, oral suction catheter, Washcloth, oral suction catheter, facial tissuesfacial tissues
Reassess frequentlyReassess frequently
Invite family to bedsideInvite family to bedside
Washcloth, oral suction catheter, Washcloth, oral suction catheter, facial tissuesfacial tissues
Reassess frequentlyReassess frequently
. . . Withdrawal protocol– part 3. . . Withdrawal protocol– part 3 After the patient diesAfter the patient dies
talk with family and stafftalk with family and staff
provide acute grief supportprovide acute grief support
Offer bereavement support to family Offer bereavement support to family membersmembers
follow up to ensure they are okayfollow up to ensure they are okay
After the patient diesAfter the patient dies
talk with family and stafftalk with family and staff
provide acute grief supportprovide acute grief support
Offer bereavement support to family Offer bereavement support to family membersmembers
follow up to ensure they are okayfollow up to ensure they are okay
Example 3: Cardiopulmonary resuscitationExample 3: Cardiopulmonary resuscitation
Establish general goals of careEstablish general goals of care
Use understandable languageUse understandable language
Avoid implying the impossibleAvoid implying the impossible
Ask about other life-prolonging Ask about other life-prolonging therapiestherapies
Affirm what you will be doingAffirm what you will be doing
Establish general goals of careEstablish general goals of care
Use understandable languageUse understandable language
Avoid implying the impossibleAvoid implying the impossible
Ask about other life-prolonging Ask about other life-prolonging therapiestherapies
Affirm what you will be doingAffirm what you will be doing
Write appropriate medical ordersWrite appropriate medical orders DNRDNR
DNIDNI
Do not transferDo not transfer
OthersOthers
POLSTPOLST
DNRDNR
DNIDNI
Do not transferDo not transfer
OthersOthers
POLSTPOLST
EEPPEECC
EEPPEECC Withholding, Withholding,
Withdrawing Withdrawing Therapy Therapy
SummarySummary
Withholding, Withholding, Withdrawing Withdrawing Therapy Therapy
SummarySummary