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Posted By: John Hardisty, MS, MSPAS, PA-C
October 05, 2021
This is a follow-up to my previous blog on palliative care. A year ago, I joined the critical care team in my hospital's ICU. For me, palliative care and withdrawing life support have been the most alien and new aspects of medicine amidst this career shift—they are aspects relatively unique to the ICU setting.
In my previous post, I discussed goals of palliative care and the importance of having lengthy discussions with family members that include weighing objective information from the critical care team, the family's faith and belief systems, and, most importantly, what the patient would want. In some cases, our discussions about goals of care with the family lead to a decision to withdraw life support. In these situations, withdrawing life support and allowing the patient to pass is the most compassionate, ethical, and medically correct thing that the ICU team can do.
Often, we see family members requesting that patients be kept on life support for months on end. However, sometimes the best objective information we can give families is that patients will not likely recover and if they do, it will be with significant debility. These are hard decisions for the ICU team and for families—talk to any ICU nurse and they will tell you the most heartbreaking patient to care for is one who is on long-term life support with little to no hope of recovery.
When a decision is made to withdraw life support, it is important to fully understand your state regulations, hospital policies, and specific ICU policies. Our ICU is blessed to have a palliative care team on duty during the day and the majority of life support withdrawal is done by their skillful hands. However, it does sometimes happen in the middle of the night, and as a critical care PA, the responsibility becomes mine. As fate would have it, I was tasked with 6 withdrawals of life support in a 72-hour period last week. It was not a great week.
Our ICU uses a computer-based order set to start the guidance. But there is also philosophy and style to make the process smooth for the patient.
As an example, our "End of Life Comfort Care" order set contains the following:
- Code status: DNR
- Vital signs minimized (stop notification of critical vital signs)
- Notify organ donation service, if pertinent
- End of life care comfort measures (an order is given confirming we are discontinuing life support)
- Turn patient every 2 hours
- Oral care (ie, suction secretions as needed)
- Insert foley catheter, if not already present
- Titrate oxygen no higher than 4 L/min of patient discomfort
- Discontinue telemetry
- Deactivate ICD/defibrillator
- Do not restart IVs, as long as there is still 1 point of access
- Consult spiritual care (our hospital has an in-house chaplain on duty at almost all times)
- Anticholinergics to help with secretions (ie, scopolamine, atropine ophthalmic solution, hyoscyamine dissolving tablet, or robinul IV injections)
- Diuretics as needed
- Bowel management
Often, family will be at the bedside. It is important that withdrawing life support is done correctly and smoothly for the patient and the family. Having an experienced physician, PA, or NP nearby to add or subtract medications, as needed, is key. Also, having an experienced nurse and respiratory therapist can make all the difference in the world: Slowly weaning the vent and drips is a judgment call that can only be made with experience. Giving additional morphine or lorazepam pushes at just the right time can also be crucial for the patient.
In preparing this post, I discussed withdrawal of life support techniques with the head of our palliative care team, our ICU pharmacist, and some of our intensivists, who appear to have experienced the fewest complications during the process. Nearly everyone agreed that the best technique is to order smaller doses, with more frequent pushes. This is more labor intensive and requires more supervision over the process; however, it appears to deliver some of the best results.
The compassionate withdrawal of life-sustaining measures can involve some of the more difficult and daunting tasks if you are relatively new in the ICU and have been focusing your energy on stabilizing and resuscitating patients. That said, it is one of the most important actions we perform for our patients. For some patients, is the absolute best thing we can do for them.