Withdrawal of Care in the ICU

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Gilbert Ross
6 years ago
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1 Withdrawal of Care in the ICU Arlene Bobonich, MD Director, Inpatient Palliative Medicine PinnacleHealth System WHO IS DRIVING THE BUS? WHERE IS THE BUS GOING? HOW DO YOU GET OFF THE BUS? WHO GETS THROWN UNDER THE BUS? Mortality rate in the ICU is about 40% 1

2 20% of all Americans receive ICU care at the end of life. (We currently do not know how many of these cases are deemed as unlikely to produce benefit) But the end point, in 1 out of 5, is still death. 1/2 of all ICU patients will not have, or will lose, the ability to make decisions within the first 24 hours

Seven domains have been identified: Patient and family centered decision making Communication with the team and patient /family Continuity of Care Emotional and practical support for the family

3 Seven domains have been identified: Patient and family centered decision making Communication with the team and patient /family Continuity of Care Emotional and practical support for the family Symptom management and comfort care Spiritual support Emotional and organizational support for the clinician SO WHO IS DRIVING THE BUS? Three measures considered essential: Assessment of the patient s decision making capacity Documentation of a surrogate within 24 hours Documentation of wishes or advanced directives 3

4 SO WHERE IS THE BUS GOING? The single most valuable principle: THE GOALS OF CARE SHOULD BE THE DRIVING FORCE FOR TECHNOLOGY NOT VICE VERSA. Consent should not be inferred from simply informing. The CONSEQUENCES OF THAT CHOICE MUST BE MADE CLEAR. 4

5 Most literature focuses on the entire ICU population and very little information exists about disease specific care at the end of life. In the seven domains other quality measures may appear self evident, But establishing a policy and even a flow sheet for provision of communication can be immeasurably helpful. ALL (MOST) caregivers must be on the same page. The ICU is a dynamic interchange of concordant/discordant clinical strategies. 5

6 Clinical practice "pearls" WE TREAT PEOPLE NOT NUMBERS. WE DO THINGS FOR PEOPLE...NOT TO PEOPLE. MULTIORGAN SYSTEM FAILURE occurs in about 20% of patients admitted to the ICU. If three organ systems are involved, the circumstances are almost invariably fatal. HOW DO YOU GET OFF THE BUS? 6

7 The goals of withdrawal are to remove processes or actions which are no longer desired and/or do not provide comfort. In actuality, when circumstances justify withholding one life sustaining treatment, strong consideration should be given to withdrawal of all life sustaining treatment. In the state of Pennsylvania withholding nutrition and fluids requires a separate order and independent decision. 7

8 In reality: Foregoing nutrition and hydration more likely leads to greater patient comfort. Withholding or withdrawing nutrition are distinct from physician assisted suicide and euthanasia. Actions whose sole goal is to hasten death are morally, ethically and legally problematic. 8

9 Things that you may not realize: In a patient with moderate or greater dementia, does a gastric tube: Reduce infection Enhance cognition Reverse delirium Reduce aspiration Reverse malnutrition Reduce infection NO NO NO NO NO NO Clinical Pearls: When talking about a feeding tube, use less emotional descriptors. Call it a gastric tube or stomach tube. Telling families you will stop feeding is wrought with emotional pain. Avoid terms like withdrawal of care, rather use words like "focus" or "emphasize" Words like" aiming for freedom from pain "or "shifting our goals" may be helpful. 9

10 How about SOB? Is there a time to NPPV? Patients with respiratory failure and DNI status have an exceptionally high mortality rate when treated with NPPV. BUT... those with CHF,COPD, a strong cough, and are fully awake may achieve symptom improvement. The withdrawal of mechanical ventilation is actually one of the few life sustaining treatments whose withdrawal can cause discomfort. 10

11 Mechanical ventilation has profound symbolic as well as pragmatic significance for both practitioners and families. The recommendations made here are based on the premise that the withdrawal of life sustaining treatments is a clinical procedure. And as such, merits the same meticulous preparation and expectation of quality that clinicians perform when they initiate life support. A stuttering course of action, partial life support is rarely justifiable. Sometimes they are part of the negotiating technique for families But vey often they are part of a physiological link for caregivers, between actions and death. 11

12 A gradual series of steps is not legally or ethically necessary, and runs the risk of exposing the patient to pain and suffering without a significant chance of benefit and often times prolongs the grief. WHAT TO TURN OFF FIRST OR LAST? The system that is most closely tied to mortal dependence should be last. Patients requiring high levels of hemodynamic support may sustain a rapid cardiac death by simply withdrawing hemodynamic support. Weaning difficulty, by history, suggests that the ventilator should be removed last. 12

13 There is almost no justification for weaning life support except the ventilator, and that should take no more than about 15 to 30 minutes. Terminal sedation should be to a Ramsay 5 to 6, that is between unresponsive and a very sluggish response to a glabellar tap. For a terminal ventilation wean: Decrease the oxygen to 21% Remove PEEP Change to SIMV (spontaneous intermittent mandatory ventilation) Reduce, then discontinue pressure support When both are zero, go to a T piece or extubate Depends upon the alarm mechanism, whether the patient may be able to or want to talk In general, the request to reintubate must be honored in spite of previous requests 13

14 The sole purpose of administering sedative agents to dying patients is to relieve symptoms. These may be "physiologically" rational or may be perceived. That is what all symptoms are. In the event of surrogate decisions, they may be the one who feels symptoms are unmanaged. But - THE PATIENT HAS RELINQUISHED THE DECISION MAKING TO THEM. At times, critically ill patients are hemodynamically unstable. They may not receive optimal sedation because of drug related hypotension or respiratory suppression. Once the decision to extubate is made, liberation from the vent is the goal. Specific dosages of medicine are less important goals (as opposed to other medications being correct), than the goals of titration to the desired effect. 14

15 No ceiling should be placed on dosages if the goal of relieving patient distress has not been achieved. The morphine drip is typically titrated to keep the respiratory rate less than 22, and the heart rate less then 100, eliminate grimace, agitation, restlessness or any other outward signs of pain. Charting should include documentation for the escalating doses. NOT "morphine up to 20 mg an hour BUT "morphine drip increased to 20 mg an hour administered for agitation-family at bedside and aware" 15

16 After adequate sedation, all alarms, monitors, ICD, vasopressors, intra-aortic balloon pumps, other medicines and nutritional support should be discontinued. IV site should remain available. WHO GETS THROWN UNDER THE BUS? 16

Sedation Hold/Interruption and Weaning Protocol ( Wake-up and Breathe )

PROTOCOL Sedation Hold/Interruption and Weaning Protocol ( Wake-up and Breathe ) Page 1 of 6 Scope: Population: Outcome: Critical care clinicians and providers. All ICU patients intubated or mechanically