Ventilatory Support Withdrawal Checklist
Prior to extubation:
• Allow family time with patient (if desired). Ask family if they would like to see a Chaplain or Social Worker or have last rites.
• Discuss with family the extubation process, expected dying process (e.g., agonal breathing), plans for symptom control, and expected timeline (death usually occurs in minutes to hours; see Chest 2010 138:289)
• Have a plan/medications ready to address air hunger, pain, and anxiety aggressively. Discuss plan/orders w/ RN.
• Do not withhold appropriate symptom management because of concern for hastening death (remember the Principle of Double Effect – your focus should be on managing symptoms, including palliative sedation if no other reasonable options). If in doubt, involve SAR/fellow/attending/pall care.
• Discuss with RT (and SAR/fellow/attending PRN) vent withdrawal plan (immediate withdrawal vs down-titration of vent support). In some cases, may continue full vent support if death expected rapidly from pressor wean.
Medications (see also Non-Pain Symptom Management page):
• STOP paralytic agents (cisatracurium) and Propofol
• Opioids: Dilaudid or morphine gtt, with frequent PRN bolus from gtt (if not already on gtt, give bolus when starting gtt. If increasing gtt, bolus as well – otherwise won’t reach new steady state for hours). Work w/ RN to provide anticipatory dosing.
• Benzos: High dose Ativan IV PRN or start Ativan/midazolam gtt (bolus when starting or increasing gtt, as with opioids)
• Consider Haldol IV PRN (anxiety/delirium) and glycopyrrolate (secretions)
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