Palliative Care and End of Life Issues: Fellow Case Report Poster - Palliative Care |

Withdrawal of Mechanical Ventilation: A Systematic Review and Approach Following Two Unusual Cases FREE TO VIEW

Michael Gale, MD; Fernando Kawai, MD; Cynthia Pan, MD; Jane Morris, RN; James Gasperino, MPH
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Division of Geriatrics and Palliative Care, New York Presbyterian Queens, Brooklyn, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):945A. doi:10.1016/j.chest.2016.08.1047
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SESSION TITLE: Fellow Case Report Poster - Palliative Care

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: There is limited data to provide a standardized approach to weaning terminally ill patients from mechanical ventilation (MV). Studies have demonstrated that having protocols in place for withdrawal of MV contributes to clinician satisfaction. However there are no standardized protocols that are uniformly accepted for such withdrawal.

CASE PRESENTATION: We review two cases of patients with terminal diagnosis who had been intubated in the MICU and found to be unweanable. After extensive conversations among the critical care team, palliative care team and patient/family; it was decided to proceed with palliative extubation. One patient was alert and able to be involved in the process of withdrawing MV, while the other patient was completely unresponsive. Upon implementing palliative extubation, the involved physicians and health care providers had different opinions about the approach and a standardized protocol was lacking. We undertook a review of the literature to identify best practices. 22 published articles regarding withdrawal of MV spanning 1983-2015 were selected. Articles were reviewed if containing data describing different processes or aspects related to withdrawal of MV in a terminal event in adult patients.

DISCUSSION: Existing literature addressed the following domains related to palliative extubation: measures of distress, premedication, medication during withdrawal, extubation considerations, method of withdrawal, survival time, and the relationship of opioids/ benzodiazepines to duration of survival. We found limited evidence to formalize a standard protocol for withdrawal of MV in terminally ill patients. We synthesized the data, and provide a structured approach to withdrawal of life support that includes the use of analgesia and anxiolytics for symptom management. We also describe a stepwise approach while terminally weaning alert/awake patients, and a one-step approach for patients who are unresponsive.

CONCLUSIONS: In caring for patients who are critically ill, ventilator dependent and not weanable, it is beneficial to incorporate an interdisciplinary palliative care approach into the ICU setting, assess patient/family-centered goals of care, and implement collaborative and evidence based process for withdrawal of MV.

Reference #1:AACN Adv Crit Care. 2007 How to withdraw Mechanical Ventilation: a systematic review of the literature.Campbell ML

DISCLOSURE: The following authors have nothing to disclose: Michael Gale, Fernando Kawai, Cynthia Pan, Jane Morris, James Gasperino

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