Withholding and withdrawing ventilatory support in adults in the intensive care unit
- Douglas B White, MD, MAS
Douglas B White, MD, MAS
- Associate Professor of Critical Care Medicine; Director, Program on Ethics and Critical Care Medicine
- University of Pittsburgh Medical Center
- Section Editors
- Robert M Arnold, MD
Robert M Arnold, MD
- Editor-in-Chief — Palliative Care
- Section Editor — General Principles of Palliative Care
- Chief, Section of Palliative Care and Medical Ethics
- University of Pittsburgh School of Medicine
- Polly E Parsons, MD
Polly E Parsons, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Critical Care
- Professor of Medicine
- University of Vermont College of Medicine
For critically ill patients in the intensive care unit (ICU), death most commonly results from the withholding or withdrawal of ventilatory support (figure 1) [1-4]. However, the decision to withhold or withdraw ventilatory support is difficult for patients, families, and clinicians. It is influenced by many factors, including the patient's prognosis, individuals' values and treatment preferences, and cultural, philosophical, and religious beliefs [5,6].
Issues related to withholding or withdrawing mechanical ventilation of critically ill patients are reviewed here, including a discussion on both ethical considerations and the practical aspects of ventilator withdrawal. Family meetings, the setting in which many decisions to withhold or withdraw ventilatory support are made, a discussion of how to respond to requests for futile and potentially inappropriate therapies, and other palliative care issues that arise in the patients treated in the ICU are discussed separately. (See "Communication in the ICU: Holding a family meeting" and "Ethics in the intensive care unit: Responding to requests for potentially inappropriate therapies in adults" and "Palliative care: Issues in the intensive care unit in adults" and "Ethics in the intensive care unit: Informed consent".)
Several national organizations have published clinical practice guidelines for end of life care and withdrawal of ventilatory support, including the Canadian Critical Care Society and the American Thoracic Society (ATS) [7-9]. The recommendations discussed below are generally consistent with these guidelines.
Ideally clinicians would discuss preferences for ventilatory support with their patients before a critical situation forces an emergency discussion. Doing so would allow families time to think about what are usually highly complex and emotionally difficult decisions. As in other areas of medicine, the patient's wishes should dictate what should happen when he or she is faced with decisions regarding ventilatory support.
If patients are not able to state (or have not previously stated) their preferences regarding ventilatory support, clinicians should make concerted efforts to understand the patient's health-related values and personal treatment goals, which, depending on the underlying illness, may be achievable (eg, relief of pain and suffering or avoidance of a prolonged dependence on ventilatory support) or not (eg, restoring health, extending life). (See "Discussing goals of care".)
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- ESTABLISHING GOALS
- Role of surrogate decision makers
- - Approaching conversations in the critically ill patient
- - Discussing withholding or withdrawing mechanical ventilation
- Discussing do-not-escalate-treatment orders
- ETHICAL MISPERCEPTIONS ABOUT FOREGOING VENTILATORY SUPPORT
- The principle of double effect
- CAUSES OF CONFLICT
- Resolving conflict
- PRACTICAL ASPECTS OF WITHDRAWING MECHANICAL VENTILATION
- Withdrawal of ventilatory support
- Measures post-extubation
- PATIENTS ON PROLONGED MECHANICAL VENTILATION
- SUMMARY AND RECOMMENDATIONS