Discontinuation of Technological support (Vent, HD)

Question 1

HIERARCHY in considering to withhold or withdraw the technological support.

Answer 1

1. Patient’s RIGHT to determine how bodies used/ INFORMED consent (Schloendorff)
2. Substituted judgment for INCOMPETENT patients (Quinlan)
3. Surrogateds decision making based on Benifit-Burden Analysis/ Best-interest priciple (Barber)

Question 2

Palliative extubation

Answer 2

• Immediate VS Terminal weaning
• Counsel families on POTENTIAL outcomes
• Turn OFF all alarms
• Discontinue paralytics and blood pressure support.
• Remove restraints
• Administer an IV bolus dose and begin an IV continuous infusion of sedating medication. Do not rely on subcutaneous or enteral drug administration as these take longer to work. For children, obtain dosing advice from a pharmacist or pediatric intensivist.
• Titrate drugs to control labored respirations and achieve the desired state of sedation prior to extubation. Testing the eyelid reflex is a common method of quickly assessing level of consciousness.
• Have additional medication drawn up and ready to administer at the bedside if needed.
• After ventilator withdrawal: If distress ensues immediate symptom control is needed. Use additional sedating medication (e.g. morphine 5-10 mg IV push q 10 min, and/or midazolam, 2-4 mg IV push q 10 min, until distress is relieved). Adjust infusion rates to maintain relief.
• Specific dosages are less important than the goal of symptom relief. A goal should be to keep the respiratory rate < 30 and eliminate grimacing and agitation.
• DISCUSS discontinuing of other life sustaining treatments: nutrition/hydration, antiotics, transfusion, dialysis.

Question 3

ADULT Palliative Extubation REGIMEN

Answer 3

Regimen A: Morphine plus Midazolam

• Good for COMATOSE patients or patients with limited consciousness and/or patients with little prior exposure to these drugs (and thus less risk of tolerance).
• Bolus: Morphine 2-10 mg; Midazolam 1-2 mg
• Infusion: Morphine 50% of the bolus dose in mg/hr; Midazolam 1 mg/hr

Regimen B: Pentobarbital

• Good for the AWAKE patient
• Bolus: 1-2 mg/kg (at rate of 50 mg/min)
• Infusion: 1-2 mg/kg/hr

Regimen C: Propofol (Adult doses)

• Good for the awake patient
• Bolus: 20-50 mg
• Infusion: 10-100 mg/hr

Question 4

Do aggressive managing symptoms after extubation hastening the death?

Answer 4

NO

Median time to death Pre intervention 37min and Post-intervention 39mins

(Treece Crit Care med 2004)

Question 5

When to WITHHOLD or WITHDRAW the dialysis?

Answer 5

1. Patients who, being fully informed and making voluntary choices, decline to begin or request dialysis be stopped.
2. Patients who no longer posses decision-making capacity, but who have previously indicated refusal of dialysis (oral or written).
3. Patients who do not posses decision-making capacity and whose surrogate declines dialysis or determines it should be discontinued.
4. Patients with irreversible, profound neurological impairment such that they lack signs of thought,sensation, purposeful behavior, and awareness of self and environment.
5. Patients whose medical conditions precludes the technical process of dialysis.

Question 6

Withdrawal dialysis

Answer 6

• The goal of dialysis is not only to prolong life by providing renal replacement therapy, but to maintain a patient’s quality of life at an acceptable level.

VOLUNTARY discontinue dialysis occures when?

• No longer serving to substantially prolong life or is only prolonging a patient’s death (e.g., a patient dying from advanced cancer or sepsis with multiorgan system failure).
• The burdens of dialysis and its complications outweigh its life-prolonging benefits to a patient (e.g., a patient with progressive frailty who is becoming bedbound, a patient with severe cognitive failure).

Demographic

older age, female, WHITE race, longer duration of dialysis, higher educational level, living alone, severe pain, and comorbidity (with chronic or progressive diseases).

Question 7

Issues surrounding dialysis withdrawal

Answer 7

• EXPLORE REASONs, especially for treatable factors: DEPRESSION, difficulties with dialysis, lack of supports
  *

Question 8

ADDRESSING dialysis phrase

Answer 8

“Dialysis will likely make _____ live longer. However – given everything that has been happening – it is not going to improve patient’s strength, memory, or ability to take care of him/herself. Based on what you’ve told me about your ___ and what is important for him/her, I would recommend withholding/stopping the dialysis as it is only serving to maintain patient in a state he/she would find unacceptable.”

Question 9

Common symptoms WHEN dialysis DISCONTINUE

Answer 9

1. confusion/agitation 70%
2. Pain (55%): Fentanyl, Methadone
3. Dyspnea (48%)
4. Nausea (36%): Haldol, Reglan
5. Twitching/Restless legs/seizures (27%):Clonazepam
6. Anxiety/psychological distress (27%):BZD, Haldol
7. Pruritis (24%): Topical hydourea, Zofran, antihistamine
8. Peripheral edema (21%): 1LPD, Bumex

Question 10

Prognosis after STOP dialysis

Answer 10

7-10 days

Question 11

What is the symptoms in ESRD WITHOUT dialysis?

Answer 11

1. Lack of energy (86%)
2. Itch (84%)
3. Drowsiness (84%)
4. Dyspnea (80%)
5. Poor concentration (76%)
6. Swelling (71%)
7. Dry mouth (69%)
8. Constipation (65%)
9. Nausea (59%)

Question 12

Drugs of choice for Renal failure patients?

Answer 12

Tylenol, Fentanyl, Methadone

Morphine and Hydromorphone (Dilaudid)

Question 13

What is the TOXIC metabolite of morphine and hydromorphone

Answer 13

• Hydromorphone-3-glucuronide and morphien-3-glucuronide
• A dose-dependent allodynia, myoclonus, and seizures

Question 14

Difference between withholding and withdrawing life-sustaining treatment?

Answer 14

• Literally: Withholding treatment is refraining from starting a therapy, whereas withdrawing treatment is stopping a therapy that has already been initiated.
• Legally: there is NOT an ethically meaningful distinction between withholding and withdrawing life-sustaining treatment.