Elective discontinuation of life-sustaining mechanical ventilation on a chronic ventilator unit

Withdrawal of medical interventions has become common in the hospital for p atients with terminal disease. Despite the widespread feeling that medical interventions may be futile in certain patients, many patients, families, a nd medical staff find withdrawal of care difficult and withdrawal of mechan ical ventilation to be the most disturbing secondary to the close proximity of withdrawal and death. Presented is a 6-year retrospective review of ele ctive withdrawal of life-sustaining mechanical ventilation on a chronic ven tilator unit (CVU) in an academic nursing home. Of the 98 patients admitted to the 19-bed CVU during this period, only 13 underwent terminal weaning T W). Statistically, these 13 patients did not differ significantly in age, g ender, race, route of nutrition, decisional capacity, or length of stay on the unit compared with the 85 patients who were not terminally wearied (t-t est P > .05). Stepwise logistic regression found that patients who were mor e alert at admission were more likely to have participated in TW (chi (2) = 5.22, coefficient for alertness P < .036). The decision to terminate mecha nical ventilation was made by patients in eight cases and by family in five cases. The first step in the process leading to TW was a discussion with the patie nt and family about plan of care, including the patient's desires for attem pted resuscitation, rehospitalization, advance directives, and family conta cts. Plan of care was reviewed informally in a weekly multidisciplinary rou nd and formally, to address each patient's care plan, in a multidisciplinar y family meeting on a regular basis. The second step was to address TW when brought up by the patient, family, or medical staff. A request for TW by a patient or surrogate was referred to the medical staff, who screened the p atient for depression or other remediable symptoms. The third step was to r efer the patient and family to another formal meeting to discuss the reques t for TW and, if needed, in the case of multiple family members, to allow q uestions to be answered and consensus to be formed. Additional meetings wer e scheduled as needed. The next step occurred once a consensus was reached to proceed with TW; a date and time was set to reconvene the patient, famil y, and anyone else who wanted to be present at the T-W. The TW process bega n when a peripheral intravenous catheter was placed and the patient was pre medicated with low doses of morphine sulfate and a benzodiazepine. After pr emedication, the patient was removed from the ventilator. The physician, nu rse, family, and physician assistant remained at the bedside and additional morphine or benzodiazepine was given, as needed, for symptom management. D eath from TW occurred in all patients, at times ranging from 2 minutes to 1 0.5 hours (average 6.2 hours). A mean total dose of 115 mg morphine and 14 mg diazepam was given for symptom control. There was no correlation between dose of these medications and duration of survival off the ventilator.