Terminal Extubation Research Articles

Pediatric Palliative Sedation (FR414)

1.Identify pediatric-specific considerations regarding palliative sedation (PS).2.Present an algorithm for when and how to implement PS for children.3.Explore family reactions to the options and experience of PS. Much has been written on the topic of PS, including endorsements by AAHPM and the National Hospice and Palliative Care Organization of PS as an intervention of “last resort.” The use of PS for children, however, has gone largely unaddressed. As is the case with much of pediatric practice, algorithms and medications have been instituted “off-label” based on adult studies and analyses. In fact, the only relevant position statement of the American Academy of Pediatrics refers to “terminal sedation” (an outdated term) with exclusive reference to articles in the adult literature. Under-recognized are the unique aspects of pediatrics that directly impact both the decision to initiate PS and the manner in which it is implemented. These include the presumption toward aggressive treatment, the application of the best interests standard rather than substituted judgment, and the greater latitude afforded parents compared to the surrogates of adult patients without decisional capacity. This session will begin with an overview by a pediatrician/ethicist of the ethicolegal landscape surrounding PS with specific reference to its application to pediatric practice. Additional considerations beyond those typically incorporated into adult treatment algorithms will be considered. Next, a pediatric anesthesiologist will review the practical aspects of implementing PS, including indications for pediatric palliative sedation and a symptom-based approach to the pharmacologic management. This will explore the use, mechanism of action, and side effects of both opioids and benzodiazepines as well as the unique uses of ketamine, dexmedetomidine, and propofol. A brief discussion of techniques for terminal extubation will be included. Finally, the parent of a child who received PS will share her experiences. Specifically, she will describe the manner in which the option of PS was presented to her. After identifying the primary considerations in deciding whether to pursue this intervention, she will describe the experience of watching her child be sedated in order to control his symptoms while at the same time knowing that he would not survive nor be able to interact meaningfully with his loved ones again.

I Need to Live Until I Die: The Inner Lives of Adolescents and Young Adults LWLTC (FR415)

Objectives 1. Identify pediatric-specific considerations regarding palliative sedation (PS). 2. Present an algorithm for when and how to implement PS for children. 3. Explore family reactions to the options and experience of PS. Much has been written on the topic of PS, including endorsements by AAHPM and the National Hospice and Palliative Care Organization of PS as an intervention of ‘‘last resort.’’ The use of PS for children, however, has gone largely unaddressed. As is the case with much of pediatric practice, algorithms and medications have been instituted ‘‘off-label’’ based on adult studies and analyses. In fact, the only relevant position statement of the American Academy of Pediatrics refers to ‘‘terminal sedation’’ (an outdated term) with exclusive reference to articles in the adult literature. Under-recognized are the unique aspects of pediatrics that directly impact both the decision to initiate PS and the manner in which it is implemented. These include the presumption toward aggressive treatment, the application of the best interests standard rather than substituted judgment, and the greater latitude afforded parents compared to the surrogates of adult patients without decisional capacity. This session will begin with an overview by a pediatrician/ethicist of the ethicolegal landscape surrounding PS with specific reference to its application to pediatric practice. Additional considerations beyond those typically incorporated into adult treatment algorithms will be considered. Next, a pediatric anesthesiologist will review the practical aspects of implementing PS, including indications for pediatric palliative sedation and a symptom-based approach to the pharmacologic management. This will explore the use, mechanism of action, and side effects of both opioids and benzodiazepines as well as the unique uses of ketamine, dexmedetomidine, and propofol. A brief discussion of techniques for terminal extubation will be included. Finally, the parent of a child who received PS will share her experiences. Specifically, she will describe the manner in which the option of PS was presented to her. After identifying the primary considerations in deciding whether to pursue this intervention, she will describe the experience of watching her child be sedated in order to control his symptoms while at the same time knowing that he would not survive nor be able to interact meaningfully with his loved ones again.

End-of-Life Care in Muslim Brain-Dead Patients

In Muslim countries, end-of-life practices in Muslim brain-dead patients are unknown. We conducted this study to evaluate this issue. We identified 42 brain-dead patients between 2001 and 2011. The expectant terminal extubation occurred only in 5. Largely due to family opposition, 2 patients remained "full code," and rests were "do not attempt resuscitation" with varying usage of "life-sustaining" therapies. Only 2 out of 24 eligible patients donated organs. There was minimal involvement of social worker, palliative team, or Muslim chaplain in the end-of-life discussions. In Muslim patients, the concept of terminal withdrawal and organ donation after brain death is still not well accepted. Future multicenter studies, involving palliative teams, should focus on improving these issues.

Monolithic Moral Frameworks: How Are the Ethics of Palliative Sedation Discussed in the Clinical Literature?

A variety of moral frameworks can assist clinicians in making ethical decisions. In examining articles on palliative sedation and terminal extubation, we were struck that bioethical discussions uniformly appealed to principlism and especially to the rule of double effect. Other moral frameworks were rarely invoked, an observation consistent with Daniel Callahan's assertion that principlism has a "blocking effect" on broader ethical deliberation. We review here the principle of double effect as it applies to clinical acts that may hasten death, and present one radically different ethical formulation developed by Dan Brock. We then offer brief examples of how clinicians might use other moral frameworks to assess the ethics of preemptive sedation for terminal extubation. We argue for greater moral pluralism in approaching end-of-life decisions.

Posterior Reversible Encephalopathy Syndrome in a Patient with Microscopic Polyangiitis (P01.127)

Objective: To discuss neurologic manifestations of microscopic polyangiitis (MPA) vasculitis. Background Central nervous system manifestations of MPA are uncommon. Only two cases of posterior reversible encephalopathy syndrome (PRES) in patients with MPA have been reported. Design/Methods: A case report. Setting: A tertiary care center. Patient: A 69-year old man with chronic kidney disease of unknown etiology came to the ED with new-onset right foot numbness. He was febrile and normotensive. Labs revealed a leukocytosis, anemia and an elevated creatinine. Urinalysis showed 21-30 wbcs, rbcs too numerous to count, 3+ protein, and 3+ blood. CT head was unremarkable. A diagnosis of MPA vasculitis was made based on serum positivity for myeloperoxidase (MPO)-ANCA and renal biopsy. He received steroids and one dose of cyclophosphamide but had a complicated hospital course, with respiratory distress requiring intubation and renal failure requiring CVVH followed by hemodialysis. On Day 28 he went from interactive and able to follow commands to acutely delirious. Hours later he had a generalized seizure and went into status epilepticus. CT scan revealed extensive edema bilaterally in the posterior portions of both hemispheres, raising concern for PRES. CT on hospital day 35 was again consistent with PRES. The patient remained intubated and sedated and was unable to recover. On Day 43, the patient9s family opted for terminal extubation. Results: Our diagnosis was PRES as indicated by the CT scans. Conclusions: The pathophysiology of PRES in patients with MPA vasculitis is unclear. Endothelial damage might predispose to PRES by increasing blood-brain barrier permeability. Our patient had renal failure and was immunosuppressed, which may have also contributed to his development of PRES. MPA itself, the renal failure that it may induce, and the agents used to treat it all may be associated with the development of PRES. Disclosure: Dr. Minen has nothing to disclose. Dr. Gold has nothing to disclose. Dr. Badjatia has nothing to disclose.

Humane terminal extubation reconsidered

Patient comfort is not assured by common practices for terminal extubation. Treatment guidelines suggest minimizing dosage of opioids and sedatives. Multiple lines of evidence indicate that clinicians are limited in their ability to recognize distress in such patients and tend to undermedicate patients in distress. Yet suffering of any significant degree should be unacceptable. For painful procedures, such as surgery, the analogous practice of postponing anesthesia until the patient evidences discomfort would never be tolerated. Waiting for signs of suffering before initiating excellent analgesia and sedation inexorably subjects patients to distress. Therefore, when death is inevitable and imminent after extubation, suffering should be anticipated, concerns about respiratory depression dismissed, and vigorous preemptive deep sedation or anesthesia provided.

Double effect: a useful rule that alone cannot justify hastening death

The rule of double effect is regularly invoked in ethical discussions about palliative sedation, terminal extubation and other clinical acts that may be viewed as hastening death for imminently dying...

The Infusion of Opioids During Terminal Withdrawal of Mechanical Ventilation in the Medical Intensive Care Unit

Context Most deaths in intensive care units occur after limitation or withdrawal of life-sustaining therapies. Often these patients require opioids to assuage suffering; yet, little has been documented concerning their use in the medical intensive care unit. Objectives To determine the dose and factors influencing the use of opioids in patients undergoing terminal withdrawal of mechanical ventilation in this setting. Methods Data were prospectively collected from 74 consecutive patients expected to die soon after extubation. The doses of morphine, effect on time to death, and relation of dose to diagnostic categories were analyzed. Results The mean (±standard deviation) dose of morphine given to patients during the last hour of mechanical ventilation was 5.3 mg/hour. Patients dying after extubation received 10.6 mg/hour just before death. Immediately before extubation, the dose correlated directly with chronic medical opioid use and sepsis with respiratory failure and inversely with coma after cardiopulmonary resuscitation or a primary neurological event. After terminal extubation, the final morphine dose correlated directly with the presence of sepsis with respiratory failure and chronic pulmonary disease. The mean time to death after terminal extubation was 152.7 ± 229.5 minutes without correlation with premorbid diagnoses. After extubation, each 1 mg/hour increment of morphine infused during the last hour of life was associated with a delay of death by 7.9 minutes ( P = 0.011). Conclusion Premorbid conditions may influence the dose of morphine given to patients undergoing terminal withdrawal of mechanical ventilation. Higher doses of morphine are associated with a longer time to death.

Chronic Constrictive Pericarditis in Association with End-Stage Renal Disease

Pericardial involvement in end-stage renal disease (ESRD) is manifested most commonly as acute uremic or dialysis pericarditis and infrequently as chronic constrictive pericarditis (CCP). We report a 27-year-old patient with a history of uncontrolled hypertension, end-stage-renal disease on hemodialysis, who presented with recurrent ascites, dyspnea, and hypotension. After diagnosis with CCP, a partial pericardiectomy was performed; however, the patient did not improve and a salvage total pericardiectomy soon followed. He continued to decompensate and expired following a terminal extubation. No definitive cause of constrictive pericarditis was found. Nonetheless, we surmise it may have developed secondary to his end-stage renal disease. A literature review revealed end-stage kidney disease as a relatively uncommon cause of CCP; only a few other such associations have thus far been reported.

Intracerebral Hemorrhage for the Palliative Care Provider: What You Need to Know

Intracerebral hemorrhage (ICH) makes up 10%-30% of all strokes. Palliative care providers are often asked to get involved with ICH cases to aid with development of short-term and long-term goals. Prognosis can be calculated using the ICH score (based on Glasgow Coma Score score, ICH volume, presence of intraventricular hemorrhage, age, and location of origin) or the Essen score (based on age, NIH Stroke Scale [NIHSS], and level of consciousness). Do-not-resuscitate (DNR) status is important to discuss with families. Expert consensus states DNR is appropriate if the patient has two of the following: severe stroke, life-threatening brain damage, or significant comorbidities. The process of withdrawing ventilatory support can differ greatly from that of a medical intensive care unit (ICU) patient. Most ICH patients die within 24 hours following extubation. Symptoms of dyspnea and pain warrant use of opioids before and after terminal extubation. In addition, treating death rattle and postextubation stridor are important interventions. Family meetings are a vital intervention to help explain prognosis, establish a plan of care, and to get all family members on the same page. Family meetings can have a rapid effect, with 66% of families opting for withdrawal of life support to decide within 24 hours of such a meeting.

End-of-life decision in a paediatric intensive care unit: decision making in light of the parents' religious beliefs

Sir: Nowadays, the practice of withholding and withdrawal of life-sustaining treatments in children is medically and ethically acceptable when these measures can no longer yield a good outcome. In North America and Europe, 28–65% of all paediatric intensive care unit (PICU) deaths follow a restriction in care [1]. However, clinicians' attitudes and actions regarding end-of-life decisions may be altered by exposure to a different culture or religion [2]. When clinicians believe that life-sustaining treatment is medically inappropriate or inhumane, they are not necessarily obliged to provide it simply because it is demanded on religious grounds by the parents. Instead, alternative religious interpretations and attempts to reach a consensus on the appropriate limits to life-sustaining treatment should be discussed [3]. A 7-year-old boy was diagnosed with a cerebellar medulloblastoma. Complete remission was initially achieved but 6 months before admission he had a relapse of the tumour without therapeutic options. He developed clinical signs of an upper airway obstruction. It was thought that a viral infection superimposed on his vocal cords paralysis was the main cause. Life-sustaining treatment was started because the viral infection was considered to be an intercurrent, curable event. He was intubated and assisted mechanical ventilation (MV) was initiated, after which he was transferred to our PICU. During the following days, his neurological condition rapidly deteriorated. No signs of pain or discomfort were observed. The attending physician informed the parents about these developments. It became apparent that the prolongation of life-sustaining treatment would not contribute to a good outcome. Since death was imminent, the attending physician discussed the possibilities of withdrawing or withholding treatment with the parents. Withdrawing treatment, i. e. stopping MV, was not an option because of the parents' religious beliefs. For them, such action seemed to be intended to hasten death and was therefore prohibited. The attending physician was concerned that the parents would also object to withdrawal of MV after diagnosis of brain death. After careful consideration, the attending physician proposed to switch to PS/CPAP ventilation, thereby respecting the wishes of the parents to continue MV. In addition, the parents accepted the explanation that cessation of the central respiratory drive meant a fatal progression of the underlying disease, so that no change to controlled MV should be made. Shortly thereafter, the boy died in the presence of his parents and sister. He had experienced a fatal apnoea while still intubated and on PS/CPAP. Despite their tragic loss, the parents were pleased at their involvement in the discussion on the end-of-life decision and satisfied that their religious convictions had been respected. There are no paediatric guidelines for withdrawal of a life-sustaining treatment like MV. The two approaches used are termed “terminal extubation”, i. e. removing the endotracheal tube without weaning ventilatory support, and “terminal weaning”, decreasing ventilator support before extubation [4]. This case report demonstrates that religious beliefs may prohibit both approaches and provides an elegant alternative in a patient with respiratory insufficiency of central origin.

Ethical Concerns that Arise from Terminal Weaning Procedures of a Ventilator Dependent Patient a Respiratory Therapists Perspective

The purpose of this article is to take a closer at look at ethical concerns that respiratory therapists face while performing terminal weaning procedures on ventilator patients. The article explains the process of removing assistive ventilation and why terminal weaning is preferred over terminal extubation. It explains why patients with brain death are easier to terminal wean from an ethical perspective. The paper provides a critical analysis of the ethical issues using the four method approach to health care ethics which includes: beneficence and nonmaleficence, patient preference, quality of life, and contextual features. The biggest obstacle therapists struggle with overcoming is moral and religious concerns regarding removal of life support. The findings showed that although terminal weaning is a highly stressful job requirement for respiratory therapists, there are protocols and procedures that the employing health care facility can offer to help alleviate some of the associated stress and improve on the situation.

Prognosis and Decision Making in Severe Stroke

An increasing number of deaths following severe stroke are due to terminal extubations. Variation in withdrawal-of-care practices suggests the possibility of unnecessary prolongation of suffering or of unwanted deaths. To review the available evidence on prognosis in mechanically ventilated stroke patients and to provide an overall framework to optimize decision making for clinicians, patients, and families. Search of MEDLINE from 1980 through March 2005 for English-language articles addressing prognosis in mechanically ventilated stroke patients. From 689 articles identified, we selected 17 for further review. We also identified factors that influence, and decision-making biases that may result, in overuse or underuse of life-sustaining therapies, with a particular emphasis on mechanical ventilation. Overall mortality among mechanically ventilated stroke patients is high, with a 30-day death rate approximating 58% (range in literature, 46%-75%). Although data are limited, among survivors as many as one third may have no or only slight disability, yet many others have severe disability. One can further refine prognosis according to knowledge of stroke syndromes, early patient characteristics, use of clinical prediction rules, and the need for continuing interventions. Factors influencing preferences for life-sustaining treatments include the severity and pattern of future clinical deficits, the probability of these deficits, and the burdens of treatments. Decision-making biases that may affect withdrawal-of-treatment decisions include erroneous prognostic estimates, inappropriate methods of communicating evidence, misunderstanding patient values and expectations, and failing to appreciate the extent to which patients can physically and psychologically adapt. Although prognosis among mechanically ventilated stroke patients is generally poor, a minority do survive without severe disability. Prognosis can be assessed according to clinical presentation and patient characteristics. There is an urgent need to better understand the marked variation in the care of these patients and to reliably measure and improve the patient-centeredness of such decisions.

Dexmedetomidine Facilitates the Withdrawal of Ventilatory Support in Palliative Care

WITHDRAWAL of ventilatory support in the setting of a terminal illness presents the challenge to the physician of maintaining the comfort of the patient and optimizing sedation and analgesia for the time that the patient has remaining to be with his or her family and friends. Opiates and benzodiazepines are most commonly used for terminal palliation, but this combination of medications has the disadvantage of depressing ventilatory drive and airway reflexes to the degree that it may hasten the patient's death. This problem has been discussed in medical and legal literature invoking the medieval theological concept of the rule of double effect to assist physicians who are faced with the need to make the distinction between euthanasia and appropriate symptom relief in the terminally ill. 1,2 Dexmedetomidine (Abbott Laboratories, Abbott Park, IL), with its highly selective α 2 agonism, provides physicians with another pharmacologic treatment option that addresses many of the possible sources of end-of life distress, 3 with less of a problem with the double effect. We report on the care of a patient where provision of palliative care and withdrawal of ventilatory support was optimized by the use of a dexmedetomidine infusion.

Extubation chez 5 patients en fin de vie en réanimation

Decisions to withhold or withdraw active life support treatment in situations with no hope of improvement remain difficult for critical-care specialists and families; they are not always well understood by the public. This report describes terminal extubation, a particular method of withdrawing ventilator support. This retrospective analysis examines the records of patients who died in our intensive care unit after a decision to withdraw active life support by stopping artificial ventilation. Extubation was proposed for patients with irreversible neurological damage and was always performed only after a standardized collective decision-making process. This process included three stages. In the initial phase, withdrawal of ventilator support was discussed at a department staff meeting. The meeting's conclusions were transcribed into the medical file, and the possibility of extubation was raised with the family during a planned interview. At least a 24-hour period of reflection was necessary before a new interview, and any opposition, hesitation or lack of understanding by the family at this first interview resulted in suspending the decision. The technical procedures for terminal extubation were also standardized. In 5 cases (4 men and one woman, with a mean age of 65 +/- 4 years), terminal extubation was decided in cooperation with the family, following an average of 3 interviews, 16 days after admission. All patients died within 3 days. So-called "terminal" extubation, very common in the United States, but much less so in France, reinforces the transparency of end-of-life decisions in intensive care units and immediately makes tangible the end of the aggressive treatment for which critical-care specialists have been reproached. Since this first series of patients, extubation has been practiced in our department, principally in situations of irreversible neurological damage.

Withdrawal of life support in the neurologic intensive care unit

To the Editor: “Terminal extubation” is a form of euthanasia, and neurologists should recognize it as such. Withdrawal of ventilation directly results in the death of the patient. Death occurred within 1 hour of extubation in 25% of the subjects in the Mayer and Kossoff study1 confirming that these patients needed ventilatory support to survive. It is not surprising that many physicians are reluctant to perform “terminal extubation” because it goes directly against one of physicians’ most preciously guarded principles (“first do no harm”). Neurologists up to now have been protective of comatose patients on ventilatory support. Brain death criteria2 were developed for use in the intensive care unit by neurologists who acknowledged their duty to guard a patient’s life against premature extubation. In a momentous volte-face , patients are now extubated to bring about their death, and the only justification is a surrogate’s subjective concern that the patient will survive with poor quality of life. We have lost the true understanding of how precious life …

Withdrawal of life support in the neurological intensive care unit.

To describe the frequency and clinical course of terminal extubation in the neurological intensive care unit, to identify factors that influence the decision to withdraw life support, and to evaluate the experiences of surrogate decision-makers. The right of patients to refuse life-prolonging treatment is widely accepted. However, it is unknown how frequently critically ill neurologic patients are removed from life support, and practice guidelines for withdrawing mechanical ventilation remain poorly defined. We reviewed the medical records of all patients cared for by the Columbia-Presbyterian neurocritical care service over a 3-year period who died, and identified a subgroup of non-brain-dead patients who were terminally extubated. We retrospectively analyzed the clinical course of these patients and interviewed their surrogate decision-makers. Of 74 non-brain-dead patients, 32 (43%) were terminally extubated. Hispanic and white patients were more likely to be extubated than were African American patients (p = 0.02). The median duration of survival after extubation was 7.5 hours; 25% died within 1 hour, and 69% within 24 hours. Depth of coma did not predict the duration of survival after extubation. The most frequent signs after extubation were agonal or labored breathing (59%) and tachypnea (34%). Morphine or fentanyl was given to relieve respiratory distress in 68% of cases; the average dose of morphine was 6.3 mg/hour (range 2.5 to 20 mg/hour). In a structured interview of 24 surrogate decision-makers, 88% were satisfied or very satisfied with the overall process, and 75% felt the patient suffered minimally before death; all but one (96%) said that they would repeat the decision to withdraw life support. Forty-three percent of our non-brain-dead patients who died were terminally extubated. The duration of survival after extubation exceeded 24 hours in one third, and was not predicted by level of consciousness. Two thirds of patients were treated with opioids for agonal respiratory distress. Most surrogate decision-makers were comfortable and satisfied with the process of withdrawing care.