Terminal ExtubationAlia Tuqan, M.D.

Goals and objectives

•Discuss withdrawal of ventilator when patients are at end of life

•Understand the ethical issues related to withdrawal of mechanical ventilator

•Review methods and treatments to keep patients comfortable when withdrawing ventilator

Introduction

•The cessation of mechanical ventilation (MV) after goals of care for a patient have changed to comfort

•A.k.a., terminal weaning when the patient is titrated off MV over a short period of time

•Avoid using the term withdrawal of care with the patients and their families as care still will be administered to the patients after the terminal extubation

Ethical Issues• Beneficence – doing good by the patient • Non-maleficence – doing no harm • Autonomy – patients have the right to refuse

treatment, including that which is life sustaining• Medical equivalence – withholding and

withdrawing MV are thought of as equal▫Sometimes patients’ families have reservations

about stopping a therapy that was already started▫ It can be useful to tell them that withdrawing

mechanical ventilation can be thought of as similar to never starting it or do-not-intubate (DNI)

Ethical Issues

•Principle of Double Effect – terminal extubation is permissible as it is intended to relieve suffering even though the undesired consequence may be to hastened death

•Allowing to die versus killing▫Terminal extubation allows for a patient to

have a natural death versus euthanasia, intentionally ending a patient’s life, which does not

Preparation

•Educate the patients and their families on what to expect▫Explain the procedure in clear, simple

terms▫Highlight that the patients will be kept

comfort throughout the process▫Discuss prognosis – sometimes patients

decline rapidly over minutes to hours while others will live for longer periods, such as days

▫Educate the patients’ families on agonal breathing

Preparation• Allow the patients and their families time and space

to process, e.g., say their goodbyes or do spiritual rituals

• Agree on a specific time that works for the patients, their families and the healthcare providers▫This allows the patients and their families to visit prior▫ It is best to choose a time, e.g., the morning, when the

hospital is fully staffed• Make sure the healthcare providers are prepared

▫Nurses should be available to administer medications▫Respiratory therapists should be called to bedside to

assist 

Preparation• Patients should have a single-occupancy room in a

quiet location• Patients should have IV access• Neuromuscular blocking agents or paralytic

medications should be discontinued ▫ In theory, paralytics could hasten a patient’s death by

decreasing ability to breathe, and, therefore, should be stopped

▫Patients on paralytics may look comfortable▫However, in reality, comfort is difficult to assess▫Patients’ symptoms may be masked because patients

are unable to express pain or other symptoms

Preparation•An end-of-life (EOL) protocol should be

followed▫Vital signs should be discontinued▫Ventilator and other alarms should be turned off▫In addition to MV, other life-sustaining

treatments (e.g., vasopressors and antibiotics) should be stopped

▫Other palliative measures should be in place e.g., pain should be controlled with analgesics

▫Painful tasks (e.g., wound care and turning) should be minimized

Protocols• Medical centers often have standard protocols for

physicians and respiratory therapists to follow• The endotracheal tube may be kept in place or

removed▫ if the tube is removed, the cuff should be deflated

prior• MV parameters (e.g., respiratory rate and tidal

volume) may be titrated down gradually (terminal weaning) or MV may be stopped abruptly once the patient is comfortable (immediate extubation)

Protocols

•With tracheostomies, the ventilator is stopped and tubing can be disconnected

•FIO2 is set to 21%•Humidified oxygen is used

Medications

•Symptoms related to terminal extubation can include pain, dyspnea and agitation

•Therefore, protocols typically include analgesics, anxiolytics, and/or anesthetics/sedatives

•The principle of anticipatory dosing (administering medications in anticipation of symptoms) should be followed

Protocols: Option 1

•Opioid + benzodiazepine▫Usually first line ▫E.g., morphine + lorazepam or midazolam▫Bolus 15 minutes prior to the procedure▫After bolusing, the patient can be started

on an opioid drip which can be up-titrated to comfort and spot-dosed benzodiazepines

▫For a non-opioid naïve patient, the patient may need to be given a larger bolus and basal rate of opioids

Protocols: Option 2

• Opioid + barbiturate ▫Usually second line when benzodiazepine

cannot be used▫E.g., phenobarbital

Protocols: Option 3

•Opioid + anesthetic▫Usually third line ▫E.g., propofol▫Can be considered palliative sedation (PS)▫Check with your medical center re:

administration policies▫Useful for patients who may be conscious

and in severe distress not controlled by other measures

Palliative Sedation • Using sedation to relieve a patient’s uncontrollable

physical symptoms typically at the EOL▫ Benzodiazepines, barbiturates and anesthetics are typically

used• When PS is being considered, physicians need to have

conversations with patients and families re: PS’ purpose of alleviating symptoms ▫ It may be necessary to distinguish between PS and

euthanasia• PS versus euthanasia

▫ Relieving a patient’s physical symptoms at the EOL versus intentionally ending a patient’s life to relieve a patient’s physical symptoms

▫ Not hastening death versus hastening death

Properly Dosed Medications Do Not Hasten Death•Mazer et al, 2011 showed that higher

doses of opioids were associated with delays in death ▫Pre-extubation, for each 1mg/hr increment

of morphine, there was a 7.9 minute delay in death

▫Pre- versus post-extubation, for each 1mg/hr increment of morphine, there was a 12.2 minute delay in death

Properly Dosed Medications Do Not Hasten Death•Chan et al, 2004 showed that higher

doses of benzodiazepines were associated with delays in death▫Pre- versus post-extubation, for each

1mg/hr increment of lorazepam, there was a 13 minute delay in death

▫There was no relationship between doses of narcotics and time of death

Respiratory Distress

•It’s important to assess and treat •Possible markers:

▫Tachypnea▫Tachycardia▫Grimacing▫Diaphragmatic or paradoxical breathing▫Use of accessory muscles▫Nasal flaring

Truog, 2004

References• J. Andrew Billings. Humane terminal extubation reconsidered: The role for

preemptive analgesia and sedation. Critical Care Medicine. 2012; 40(2): 625-630.

• J. Andrew Billings. Terminal Extubation of the Alert Patient. Journal of Palliative Medicine. 2011; 14(7): 800-801. 

• J. Andrew Billings and Larry R. Churchill. Monolithic Moral Frameworks: How Are the Ethics of Palliative Sedation Discussed in the Clinical Literature?” Journal of Palliative Medicine. 2012; 15(6): 709-713.

• Jeannie D. Chan, Patsy D. Treece, Ruth A. Engelberg, Lauren Crowley, Gordon D. Rubenfield, Kenneth P. Steinberg, and J. Randall Curtis. Narcotic and Benzodiazepine Use After Withdrawal of Life Support. Chest. 2004; 126: 286-293.

• Mark A. Mazer, Chad M. Alligood, and Qiang Wu. The Infusion of Opioids During Terminal Withdrawal of Mechanical Ventilation in the Medical Intensive Care Unit. Journal of Pain and Symptom Management. 2011; 42(1): 44-51.

• Ryan R. Nash and Leonard J. Nelson. U6: Ethical and Legal Issues. American Academy of Hospice and Palliative Medicine. 2012.

• Joseph Shiga. Discontinuation of Technological Support. AAHPM Intensive Board Review Course DVD. 2012.

References• Robert D. Truog, Margaret L. Campbell, J. Randall Curtis, Curtis E. Haas, John

M. Luce, Gordon D. Rubenfield, Cynda Hylton Rushton, and David C. Kaufman. Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine. 2008; 36(3): 953-963.

• Rodney O. Tucker and Ashley C. Nichols. U4: Managing Non-Pain Symptoms. American Academy of Hospice and Palliative Medicine. 2012.

• Charles von Gunten and David E. Weissman. #33: Ventilator Withdrawal Protocol, 2nd edition. Fast Facts and Concepts. End of Life/Palliative Education Resource Center, Medical College of Wisconsin.

• Charles von Gunten and David E. Weissman. #34: Symptom Control for Ventilator Withdrawal in the Dying Patient, 2nd edition. Fast Facts and Concepts. End of Life/Palliative Education Resource Center, Medical College of Wisconsin.

• Charles von Gunten and David E. Weissman. #35: Information for Patients and Families About Ventilator Withdrawal, 2nd edition. Fast Facts and Concepts. End of Life/Palliative Education Resource Center, Medical College of Wisconsin.