Withholding and withdrawing ventilatory support in adults in the intensive care unit
- Douglas B White, MD, MAS
Douglas B White, MD, MAS
- Vice Chair and Professor of Critical Care Medicine; Director, Program on Ethics and Critical Care Medicine
- University of Pittsburgh School of Medicine
- 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".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Fisher M. Ethical issues in the intensive care unit. Curr Opin Crit Care 2004; 10:292.
- Manara AR, Pittman JA, Braddon FE. Reasons for withdrawing treatment in patients receiving intensive care. Anaesthesia 1998; 53:523.
- Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med 1998; 158:1163.
- Sprung CL, Cohen SL, Sjokvist P, et al. End-of-life practices in European intensive care units: the Ethicus Study. JAMA 2003; 290:790.
- Curtis JR, Vincent JL. Ethics and end-of-life care for adults in the intensive care unit. Lancet 2010; 376:1347.
- Huynh TN, Walling AM, Le TX, et al. Factors associated with palliative withdrawal of mechanical ventilation and time to death after withdrawal. J Palliat Med 2013; 16:1368.
- Truog RD, Campbell ML, Curtis JR, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med 2008; 36:953.
- Lanken PN, Terry PB, Delisser HM, et al. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008; 177:912.
- Downar J, Delaney JW, Hawryluck L, Kenny L. Guidelines for the withdrawal of life-sustaining measures. Intensive Care Med 2016; 42:1003.
- Luce JM. End-of-life decision making in the intensive care unit. Am J Respir Crit Care Med 2010; 182:6.
- Kon AA, Davidson JE, Morrison W, et al. Shared Decision-Making in Intensive Care Units. Executive Summary of the American College of Critical Care Medicine and American Thoracic Society Policy Statement. Am J Respir Crit Care Med 2016; 193:1334.
- White DB, Braddock CH 3rd, Bereknyei S, Curtis JR. Toward shared decision making at the end of life in intensive care units: opportunities for improvement. Arch Intern Med 2007; 167:461.
- Pearlman RA, Cain KC, Patrick DL, et al. Insights pertaining to patient assessments of states worse than death. J Clin Ethics 1993; 4:33.
- Patrick DL, Starks HE, Cain KC, et al. Measuring preferences for health states worse than death. Med Decis Making 1994; 14:9.
- Cruzan v Missouri Department of Health, 497 US 261, 110 SCt 2841 (1990).
- Wilson WC, Smedira NG, Fink C, et al. Ordering and administration of sedatives and analgesics during the withholding and withdrawal of life support from critically ill patients. JAMA 1992; 267:949.
- Vacco v Quill, 117 SCt 2293 (1997).
- Breen CM, Abernethy AP, Abbott KH, Tulsky JA. Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med 2001; 16:283.
- Abbott KH, Sago JG, Breen CM, et al. Families looking back: one year after discussion of withdrawal or withholding of life-sustaining support. Crit Care Med 2001; 29:197.
- Azoulay E, Timsit JF, Sprung CL, et al. Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med 2009; 180:853.
- McDonagh JR, Elliott TB, Engelberg RA, et al. Family satisfaction with family conferences about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction. Crit Care Med 2004; 32:1484.
- Arnold RM, Kellum J. Moral justifications for surrogate decision making in the intensive care unit: implications and limitations. Crit Care Med 2003; 31:S347.
- Levy MM. End-of-life care in the intensive care unit: can we do better? Crit Care Med 2001; 29:N56.
- Hanson LC, Danis M, Garrett J. What is wrong with end-of-life care? Opinions of bereaved family members. J Am Geriatr Soc 1997; 45:1339.
- Kutner JS, Steiner JF, Corbett KK, et al. Information needs in terminal illness. Soc Sci Med 1999; 48:1341.
- Azoulay E, Chevret S, Leleu G, et al. Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med 2000; 28:3044.
- Pochard F, Azoulay E, Chevret S, et al. Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity. Crit Care Med 2001; 29:1893.
- Wendler D, Rid A. Systematic review: the effect on surrogates of making treatment decisions for others. Ann Intern Med 2011; 154:336.
- Prendergast TJ. Resolving conflicts surrounding end-of-life care. New Horiz 1997; 5:62.
- Garros D, Rosychuk RJ, Cox PN. Circumstances surrounding end of life in a pediatric intensive care unit. Pediatrics 2003; 112:e371.
- Schneiderman LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA 2003; 290:1166.
- Chochinov HM. Dying, dignity, and new horizons in palliative end-of-life care. CA Cancer J Clin 2006; 56:84.
- Bülow HH, Sprung CL, Reinhart K, et al. The world's major religions' points of view on end-of-life decisions in the intensive care unit. Intensive Care Med 2008; 34:423.
- Campbell ML, Yarandi HN, Mendez M. A Two-Group Trial of a Terminal Ventilator Withdrawal Algorithm: Pilot Testing. J Palliat Med 2015; 18:781.
- Treece PD, Engelberg RA, Crowley L, et al. Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit. Crit Care Med 2004; 32:1141.
- Truog RD, Cist AF, Brackett SE, et al. Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 2001; 29:2332.
- Cook D, Rocker G, Marshall J, et al. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med 2003; 349:1123.
- Cooke CR, Hotchkin DL, Engelberg RA, et al. Predictors of time to death after terminal withdrawal of mechanical ventilation in the ICU. Chest 2010; 138:289.
- 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