EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Osteopathic...

EEPPEECC

American Osteopathic AssociationAOA: Treating our Family and Yours

Osteopathic EPECOsteopathic EPEC Osteopathic EPECOsteopathic EPEC Education for Osteopathic Physicians on End-of-Life

Care

Based on The EPEC Project, created by the American Medical Association and supported by the Robert Wood Johnson Foundation. Adapted by the American Osteopathic Association for educational

use.

American Osteopathic AssociationAOA: Treating Our Family and Yours

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Module 11

Withholding, Withdrawing Treatment

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Objectives• Know the principles for

withholding or withdrawing therapy

• Apply these principles to the withholding or withdrawal of• Artificial feeding, hydration

• Ventilation

• Cardiopulmonary resuscitation

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Role of the physician . . .• The physician helps the patient

and family • Elucidate their own values

• Decide about life-sustaining treatments

• Dispel misconceptions

• Understand goals of care

• Facilitate decisions, reassess regularly

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. . . Role of the physician• Discuss alternatives

• Including palliative and hospice care

• Document preferences, medical orders

• Involve, inform other team members

• Assure comfort, non-abandonment

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Common concerns . . .• Legally required to “do

everything?”

• Is withdrawal, withholding euthanasia?

• Are you killing the patient when you remove a ventilator or treat pain?

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. . . Common concerns• Can the treatment of

symptoms constitute euthanasia?

• Is the use of substantial doses of opioids euthanasia?

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Life-sustaining treatments• Resuscitation

• Elective intubation

• Surgery

• Dialysis

• Blood transfusions, blood products

• Diagnostic tests

• Artificial nutrition, hydration

• Antibiotics

• Other treatments

• Future hospital, ICU admissions

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8-step protocol to discuss treatment preferences . . .1. Be familiar with policies,

statutes

2. Appropriate setting for the discussion

3. Ask the patient, family what they understand

4. Discuss general goals of care

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. . . 8-step protocol to discuss treatment preferences

5. Establish context for the discussion

6. Discuss specific treatment preferences

7. Respond to emotions

8. Establish and implement the plan

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Aspects of informed consent• Problem treatment would address

• What is involved in the treatment / procedure

• What is likely to happen if the patient decides not to have the treatment

• Treatment benefits

• Treatment burdens

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Example 1: Artifical nutrition, hydration• Difficult to discuss

• Food, water are symbols of caring

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Review goals of care

• Establish overall goals of care

• Will artificial feeding, hydration help achieve these goals?

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Address misperceptions• Cause of poor appetite,

fatigue

• Relief of dry mouth

• Delirium

• Urine output

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Help family with need to give care

• Identify feelings, emotional needs

• Identify other ways to demonstrate caring• Teach the skills they need

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Normal dying• Loss of appetite

• Decreased oral fluid intake

• Artificial food / fluids may make situation worse• Breathlessness• Edema• Ascites• Nausea / vomiting

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Example 2: Ventilator withdrawal• Rare, challenging

• Ask for assistance

• Assess appropriateness of request

• Role in achieving overall goals of care

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Immediate extubation• Remove the endotracheal tube

after appropriate suctioning

• Give humidified air or oxygen to prevent the airway from drying

• Ethically sound practice

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Terminal weaning• Rate, PEEP, oxygen levels are

decreased first

• Over 30–60 minutes or longer

• A Briggs T piece may be used in place of the ventilator

• Patients may then be extubated

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Ensure patient comfort• Anticipate and prevent

discomfort, offer OMT when indicated

• Have anxiolytics, opioids immediately available

• Titrate rapidly to comfort

• Be present to assess, reevaluate

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Prevent symptoms

• Breathlessness• Opioids

• Anxiety• Benzodiazepines

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Preparing for ventilator withdrawal• Determine degree of desired

consciousness

• Bolus 2-20 mg morphine IV, then continuous infusion

• Bolus 1-2 mg midazolam IV, then continuous infusion

• Titrate to degree of consciousness, comfort

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Prepare the family . . .• Describe the procedure

• Reassure that comfort is a primary concern

• Medication is available

• Patient may need to sleep to be comfortable

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. . . Prepare the family• Involuntary movements

• Provide love and support

• Describe uncertainty

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Prior to withdrawal

• Prior to procedure• Discussion and agreement to

discontinue with patient (if conscious)

with family, nurses, respiratory therapists

• Document on the patient’s chart

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Withdrawal Protocol -– Part 1• Procedure

• Shut off alarms• Remove restraints • NG tube is removed • Family is invited into the room• Pressors are turned off• Parents may hold child

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Withdrawal protocol -- Part 2• Establish adequate symptom

control prior to extubation

• Have medications IN HAND • Midazolam, lorazepam, or diazepam

• Set FiO2 to 21%

• Adjust medications

• Remove the ET tube

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Withdrawal Protocol -- Part 3 . . .

• Invite family to bedside

• Washcloth, oral suction catheter, facial tissues

• Reassess frequently

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. . . Withdrawal Protocol – Part 3• After the patient dies

• Talk with family and staff

• Provide acute grief support

• Offer bereavement support to family members• Follow up to ensure they are

okay

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Example 3: Cardiopulmonary resuscitation• Establish general goals of care

• Use understandable language

• Avoid implying the impossible

• Ask about other life-prolonging therapies

• Affirm what you will be doing

• Clarify that resuscitation really means an attempt with no guarantee of success

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Write appropriate medical orders

• DNR

• DNI

• Do not transfer

• Others

• POLST

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Withholding, Withdrawing Treatment

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