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Withholding and withdrawing ventilatory support in adults in the intensive care unit

Author
Douglas B White, MD, MAS
Section Editors
Robert M Arnold, MD
Polly E Parsons, MD
Deputy Editor
Geraldine Finlay, MD

INTRODUCTION

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".)

GUIDELINES

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.

ESTABLISHING GOALS

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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Literature review current through: May 2017. | This topic last updated: Jun 24, 2016.
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