Last Days of Life (PDQ®): Supportive care - Health Professional Information [NCI] - Ethical Issues
Fewer patients with advanced cancer will undergo resuscitation and ventilatory support when discussions regarding goals of care and advance directives begin early in the course of the disease. However, when advance directives are not available or when the directives are not adequately communicated, intubation may occur despite low likelihood of survival.
When ventilatory support appears to be medically futile or is no longer consistent with the patient's (or family's or proxy's) goals of care, ventilator withdrawal to allow death may take place. Extensive discussions must first take place with patients (if they are able) and family members to help them understand the rationale for and process of withdrawal. When no advance directive is available and a patient can no longer communicate, it is helpful to reinterpret in a more realistic light, or reframe for family members, that they are not making a decision to "pull the plug" for their loved one. Rather, they are helping the health care team interpret their loved one's wishes or discontinuing a treatment that is no longer considered effective. Such reframing is essential to help family members and significant others understand that the underlying disease process, and not ventilator withdrawal, is the cause of the patient's death.
Two methods of withdrawal have been described: immediate extubation and terminal weaning. Immediate extubation includes providing parenteral opioids for analgesia and sedating agents such as midazolam, suctioning to remove excess secretions, setting the ventilator to "no assist" and turning off all alarms, and deflating the cuff and removing the endotracheal tube. Gentle suctioning of the oral cavity may be necessary, but aggressive and deep suctioning should be avoided. In some cases, patients may appear to be in significant distress. Analgesics and sedatives should be provided even if the patient is comatose. Family members and others who are present should be warned that some movements may occur after extubation, even in patients who are brain dead. Such movements are probably caused by hypoxia and may include gasping, moving extremities, or sitting up in bed. Immediate extubation is generally chosen when a patient is brain dead, when a patient is comatose and unlikely to experience any suffering, or when a patient prefers a more rapid procedure.
Terminal withdrawal entails a more gradual process. Ventilator rate, oxygen levels, and positive end-expiratory pressure are decreased gradually over a period of 30 minutes to a few hours. A patient who survives may be placed on a T-piece; this may be left in place, or extubation may proceed. There is some evidence that the gradual process in a patient who may experience distress allows clinicians to assess pain and dyspnea and to modify the sedative and analgesic regimen accordingly. In a study of 31 patients undergoing terminal weaning, most patients remained comfortable, as assessed by a variety of physiologic measures, when low doses of opioids and benzodiazepines were administered. The average time to death in this study was 24 hours, although two patients survived to be discharged to hospice.