For this reason, we avoid the use of lorazepam as a sedative for symptom control. In some situations, midazolam can be effective when given as adjunct therapy to morphine in order to alleviate dyspnea [ 39 ]. There is no evidence that the use of benzodiazepines to treat discomfort after withdrawal of mechanical ventilation hastens death in palliative [ 40 ] or ICU patients [ 26 , 31 , 33 ]. Respiratory rates do not decrease to fatal levels when patients are given palliative sedation [ 35 ].
We recommend midazolam or propofol Fig. Midazolam has a rapid onset of action and is easily titrated. In patients with prolonged mechanical ventilation, sedation is problematic because tolerance can be an especially difficult problem in the palliative phase [ 41 ]. Propofol also has an antiemetic effect, but can be associated with severe myalgia and also cannot be given subcutaneously, which could be a problem in some cases.
Some physicians choose to continue or initiate neuromuscular blocking agents after withdrawal of ventilation, while others believe that this constitutes deliberate termination of life and is therefore unethical [ 42 ].
In end-of-life care, in almost all patients, comfort can be achieved by adequate dosing of opioids and benzodiazepines or barbiturates without the use of neuromuscular blocking agents, which can and should be reversed within a short period. Neuromuscular blocking agents produce only the appearance of comfort [ 19 ] and deliberately terminate life as effect of the iatrogenic neuromuscular blockage in the absence of mechanical ventilation in patients.
The agents are often continued or administered for prevention of gasping during the dying process. The half-life of these agents can often be hours and is frequently longer in patients with organ failure. We believe there is no place for neuromuscular blocking agents in the treatment of dying patients after withdrawal of ventilation. Any existing therapeutic rationale is lost in the process of treatment withdrawal.
It is only in patients who have received the agents in large doses, where neuromuscular function can only be partially restored due to organ failure and extreme fatigue, that an ethical challenge exists.
Restoration of neuromuscular function can delay the actual withdrawal of mechanical ventilation beyond a point that is ethically defendable, producing more harm than benefit. These patients will not survive after withdrawal of ventilation and will die within minutes to hours, even without the influence of neuromuscular paralysis. The activity of any residual neuromuscular blocking agents can then not be seen as deliberate termination of life. Excessive broncho-pulmonary secretion is common in ICU patients after withdrawal of prolonged ventilation and can give rise to the development of a death rattle, which is often distressing for relatives to witness.
In ICU patients, iatrogenic overhydration and prolonged mechanical ventilation are common causes of this problem. Withdrawal of mechanical ventilation should always be preceded by withdrawal of all artificial hydration and feeding.
Furosemide should be given in cases of iatrogenic overhydration to reduce the risk of excessive broncho-pulmonary secretion and death rattle and to prevent airway obstruction and bronchospasm [ 43 , 44 ]. Dying patients are usually too weak to expectorate or swallow the migrating secretions. Sputum usually only accumulates in these areas if there is significant impairment of the cough reflex, as in coma or near death.
Most patients appear to be unaware of their rattling respiration due to altered consciousness, and as long as they do not suffer, there is no ethical demand to treat it from the perspective of the patient. Only a few palliative care nurses felt that death rattle distressed the patient [ 45 ]. The primary aim of preventing or treating the noisy breathing is to reduce the distress of relatives of the patients and caregivers.
We recommend administration of 20 mg Butylscopolamine or 0. The decision to remove the endotracheal tube should be a secondary decision following discontinuation of ventilation. Post-extubation stridor is a potential source of distress, especially for the relatives and caregivers. Two-thirds of French caregivers felt that extubation should never be considered because it might worsen distress and may have a causal association with death.
Fartoukh et al. They recommend nasal oxygen therapy immediately after extubation and in the case of dyspnea, corticosteroid treatment with a nebulizer. Increased sedation and analgesia were given in the case of discomfort stridor and asphyxia and scopolamine was given in accordance with the amount of respiratory secretions.
Stridor is the iatrogenic result of endotracheal intubation, which should be prevented and treated when it is distressing for the patient or their relatives. Gasping, however, is something that cannot be treated and in contrast with post-extubation stridor, is a normal sign of dying. For this reason we do object to routine administration of oxygen after extubation. This should be explained to the relatives. Before mechanical ventilation is withdrawn, the ICU staff should discuss with the relatives of the patient the intended withdrawal procedure, prepare for distressing symptoms, and the expected chance of survival [ 6 ].
The perceptions the relatives have regarding suffering and distress of the patient are important determinants for palliative care after withdrawal of life support. Explanation of the possible symptoms and of measures to counteract those symptoms may allow them to rest easier and reduce anxiety.
ICU nurses prepare the relatives of patients mostly by describing physical sensations and symptoms [ 50 ]. Some patients will not die within minutes or hours after withdrawal of mechanical ventilation. Some will even survive the ICU [ 5 ].
In our experience, most often, this concerns patients with severe cerebral catastrophes, but with intact brainstem and other organ functions. Physicians should be aware of this when informing the relatives about prognosis of survival. For relatives, it is paramount that they see that their loved one die without significant distress and that dying should be as natural as can be. For this reason, we recommend a two-phase, 6-h period for the process of withdrawal of mechanical ventilation, taking the aforementioned aspects into consideration Fig.
In the first phase, lasting from 6 h to 30 min before actual withdrawal of mechanical ventilation and removal of the endotracheal tube, the focus is on sedation, analgesia, prevention of DARD, post-extubation stridor, and excessive broncho-pulmonary secretions as the result of overhydration. In the second phase, 30 min before actual withdrawal of mechanical ventilation and removal of the endotracheal tube, the focus is on prevention of death rattle by means of medication.
The actual phase of discontinuation of mechanical ventilation can be very short, but thoughtful anticipation of distressing symptoms takes more time. Given that the patient has serious respiratory or ventilatory insufficiency, multiple organ failure, extremely diseased lungs, or severe neurological dysfunction, withdrawal of mechanical ventilation and subsequent removal of an endotracheal tube often induces or hastens death.
There is an ethical mandate to both anticipate and treat iatrogenic induced symptoms such as pain, DARD, anxiety, delirium, post-extubation stridor, and excessive broncho-pulmonary secretions resulting from overhydration. This makes the process of withdrawal of mechanical ventilation in ICU patients a thoughtful process, taking palliative actions instead of fast terminal actions. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author s and source are credited.
National Center for Biotechnology Information , U. Intensive Care Medicine. Intensive Care Med. Published online May Kompanje , B. Author information Article notes Copyright and License information Disclaimer. Kompanje, Email: ln. Corresponding author.
Received Nov 21; Accepted Feb This article has been cited by other articles in PMC. Abstract Background A considerable number of patients admitted to the intensive care unit ICU die following withdrawal of mechanical ventilation. Methods We analyzed existing treatment strategies in distressing symptoms after discontinuation of mechanical ventilation.
Conclusion The actual period of discontinuation of mechanical ventilation can be very short, but thoughtful anticipation of distressing symptoms takes time. Introduction A considerable number of patients admitted to the intensive care unit ICU die following withdrawal of mechanical ventilation [ 1 — 9 ].
Care before withdrawal of mechanical ventilation should include: Anticipation of pain, dyspnea associated respiratory distress DARD , and terminal restlessness and treatment with adequate administration of opioids and sedatives.
Treatment of distressing symptoms when they occur despite anticipation. Palliative sedation Palliative sedation is defined as deliberately inducing and maintaining deep sleep for the relief of intractable physical and mental symptoms in the last hours or days of life.
Open in a separate window. Neuromuscular blocking Some physicians choose to continue or initiate neuromuscular blocking agents after withdrawal of ventilation, while others believe that this constitutes deliberate termination of life and is therefore unethical [ 42 ].
Anticipation of excessive secretion Excessive broncho-pulmonary secretion is common in ICU patients after withdrawal of prolonged ventilation and can give rise to the development of a death rattle, which is often distressing for relatives to witness.
Extubation and post-extubation stridor The decision to remove the endotracheal tube should be a secondary decision following discontinuation of ventilation. Temporary postural drainage can be used to decrease the volume of secretions, and anticholinergic medications can also be used to decrease formation of secretions.
Patients can end up on life support, even in unexpected circumstances. Ventilator withdrawal with expected death is a complex process, now considered an ethically and morally acceptable practice. Familiarity and literature on this topic are increasing. Life expectancy following withdrawal varies from minutes up to weeks.
Critical care providers should be comfortable with counseling families before ventilator withdrawal and the process and symptom management surrounding ventilator withdrawal. Clinical Briefs in Primary Care. Reprints Share. Patient passports aim to speed appropriate care for medically complex children presenting to ED. Table 1. Table 2. Table 3. Report Abusive Comment Thank you for helping us to improve our forums.
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Help Search About Us. Process of Ventilator Withdrawal 4, Symptom Management After Ventilator Withdrawal 4, Dyspnea and Pain. Morphine Hydromorphone Fentanyl. Midazolam Lorazepam. Oropharyngeal secretions.
Scopolamine Atropine Glycopyrrolate. Transdermal Sublingual eye drops, off-label IV infusion or bolus. Patients who are on long-term ventilation may require a feeding tube directly inserted into the nose or mouth, or through a hole made in the stomach. The use of sedation often depends on the patient; a patient who is calm during normal life is usually calm on a ventilator while in an ICU unit. While they may be able to sit up in bed or in a chair, their mobility is otherwise limited.
The medical team that closely monitors patients on a ventilator includes: doctors, nurses, respiratory therapists, X-ray technicians, and more. Weaning is the process of taking someone off of a ventilator, so that they may begin to breathe on their own. If you have a family member or loved one on a ventilator, here are some things you should know: 1. What is a Ventilator? How Does a Ventilator Work? Who Needs a Ventilator?
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