PALLIATIVE WEANING AND EXTUBATION Flashcards
Mortality in ICU
Mortality in ICU is generally ~20%
35-56% of those are after a decision has been made to withdraw life support or life sustaining treatments.
Rt Role in EOLC
- RTs are more frequently at the bedside to assist in withdrawal of life support and therefor participate in EOL often
- This can lead to burnout
- Most discomfort/reluctance of the RT in ELOC lies with the lack of training/resource/support
- Most training for palliation is done for the physician
- RN are the profession that spends the most time at the bedside at EOL, however we are present more frequently at EOLC in the ICU
Traditional Role of RRT in EOLC
Technical and Task Oriented
RN will call for RT when it is time to extubate
RT will have very little interaction with the family
Evolution of RT role in EOLC
- RT are gaining more interest in being involved in EOLC
- There is more education in regard to communication, conflict resolution, and distress
- Well-being of care providers is now more valued and recognized
- Ex. Debriefs
- Canadian guidelines for withdrawal of care at EOL is currently being worked on
- At out site we are encouraged to participate in family conference
RRTs and Family Conferences
Challenges
A busy unit/time management
Not emotionally prepared
Confidence, not knowing what to say or do
Changing the behavior and culture at a site
Not being invited/feeling welcome
Too many people already attending
Not every conference starts out or ends in EOL conversations
RRTs and Family Conferences
Benefits
Better understanding of Survivor/Family needs, perceptions, stage of grief/acceptance which makes the extubation easier emotionally
Facilitates a coordinated team approach
Professionalism: Promotes the profession. Builds rapport with team members
Processing your own emotions associated with grief, death, and dying
Addresses the family concern about knowing the person extubating.
The biggest opportunity is that it gives you an opportunity to influence this process- using your new skills of course. But most satisfying is when you know you’ve made this a good death… or at least a better one than may have occurred.
Survivor/Family Perspective in EOLC
- Life support is though of as the ventilator and not IV meds
- Generally IV meds are not seen as any different the antibotics and are help the patient rather than keeping them alive
- Often perspectives are based on what they’ve seen on TV and urban society is more disconnected
- On TV 75% of CPR is successful where in reality successful CPR is only about 8% and only 3% will return to normal life
- When people have been asked what they want they say they want a peaceful, painless death
- When asked about modalities of life support even in the face of non-curative disease 80-90% of physician choose to not go on life support
- In some cultures suffering is an expected part of life and life is sacred so they will not want to pull the plug
View of Death Has Changed
It is more common to view death as a medical failure rather than a natural conclusion of life
Pneumonia used to be known as an Old Man’s Friend
We are more separated from death then in the past
Prior to the industrial revolution we would raise our own food
We used to live with our grandparents and we saw death
Now 80% of the population is urban, our grandparents are in Nursing homes
Survivor Distress and Experiences
Distress can come from not knowing who the person that is extubating their loved on
there is a preference for less equitment and more natural enviroemnt
Distress can come from: Not knowing what to expect, helplessness, Guilt.
Stages of Grief
Disbelief
Denial
Anger
Guilt
Acceptance
Grief/Sorrow
EOLC From the Literature
Family members expect that the healthcare professionals demonstrate expert professional skills and this expectation is meet through focusing primary attention on the care of the person rather than on the machine
The behaviors of the health care providers and institutional setting during end of life care will have enormous impact on family function and development
Families expect that we show we care more about the patient, than the equipment and our words and actions can significantly affect their grief processing and sense of well-being.
Care provider conflict and distress at EOL
More common among practitioners than previously acknowledged
RRTs have described feeling like an Angel or Agent of death1
PERCEPTIONS of suffering
Ethical Dilemmas
Personal beliefs and experience
The Palliative Ventilation Weaning Pathway
What is it?
This is an algorithm that has been developed in conjunction with Surviving Family members in order to help the decision-making process and clarify expectations for both the caregiver and family
The Palliative Ventilation Weaning Pathway
Rational for Pathway
Standardize practice, expectations, skills.
Provide enough structure for newer staff but latitude for more experienced.
Reduce distress felt by families.
Reduce distress felt by practitioners.
The Palliative Ventilation Weaning Pathway
Divided into 2 parts
The pathway is divide into weaning, airway management with airway management focusing on extubation as the primary objective
The is the very first thing you should do in the Palliative Ventilation Weaning Pathway
The very thing you need to do is to confirm End of Life Care Order which has to be a written order
There should be a discussion with the team and the family
Right after you confirm the EOLC you should consider what
Right after your confirm EOLC Order you should consider a Multidisciplinary EOL Checklist which should include
- Making a plan
- Order of withdrawal
- Discuss your expectations and agreement
- Discuss family expectations
- The trend is to have more family members presence and is this is allowed then there should be someone with the family in order to discuss and answer medical questions
What is the 1st Assessment you would do
Determine whether the patient is breathing Spontaneously
No-Check to see whether there is paralytics onboard and if there is you need to have a discussion with the physician about waiting till they are excreted out. If there is no paralystic and no spontaneous breathing then begin airway management
Yes-Begin weaning procedure
*If the patient is declared brain dead then go straight to extubation no airway management is needed
Weaning Procedure
- Reassess with the RN
- Sedation needs, pt comfort, family concerns
- Confirm plan with Family and RN
- Begin Sympton Titrated Breathing Trial
DONT FORGET TO CHANGE THE ALARMS
Begin Sympton Titrated Breathing Trial
RRT to: Change to PSV 5-10 cmH2O (goal <7cmH2O), Maintain current FiO2, decrease PEEP 0-5 cmH2O
RN to: Increase sedation with goals of alleviating signs of respiratory distress and Tobin <105
Titration of meds should be performed appropraitely in consultation with RT/MD
Ideally this process should take 5-10 minutes
Is the Weaning Trial Complete
Yes- Go to Airway Management Path
No- Return to sympton Titrated Breathing Trial, reassess sedation needs with RN
Keep it under 5 min
The main thing is checking whether the patient is comfortable
Airway Management Pathway
Are There
- Excessive Secretions >30 sxn passes/24 hr AND unresponsive to trial of drying agents
- Compromise airway (ex. trauma, tumor, anatomical anomaly etc) OR Family preference to leave A/x insitu
No- Extubation
Yes-Leave Airway Insitu
Of course you may have a massive airway tumor, or tracheal malacia that does not want to be intubated at EOL. Their choice- should be given to them with a clear understanding of what to expect, and a strong rapid plan for rapid sedation.
Extubation
- Explain procedure to the family, including possivble expectation once the patient is extubated
- Extubate the patient to RA
- Maintain Pt. Comfort
- Positioning
- Bronchial Hygiene
- OPA/NPA and Suction as needed
Document procedure in CIS
Airway Insitu
Physican Consult (if not pre-planned): If ETT T-piece vs. RA
Maintain ETT/Trach:
- Suction as required (before and after)
- Power off ventilator
- Disconnect circuit
- If T-piece/Trach
- Set up cold neb to minimal O2 settings
Document Procedure in CIS
For Pulmonary Edema/Hemorrhage
A tip or trick- for pulmonary edema/hemorrhage, consider using an HME at the end of the ETT with the extension tubing- but be prepared to change it often/teach the RN to do so.
Order of disconnect/power off
Order of disconnect/power off is arbitrary or preference. This is how the physician wrote it. One advantage may be if there are excessive secretions/pulmonary edema .. But also, alarms are completely avoided for sure. It is likely an equipment dependent issue as well.
Weaning Procedure Key Points
- Weaning should delay extubation
- Extubation is preferred over T-piece in order to keep EOLC as natural as possible
- Keep in close communication with RN regarding perceptions of pain, discomfort; as well as when any inotropes will be weaned.
- Use lowest comfortablePSV, FiO2 21%, weaning as tolerated with sedation as needed.
- In Lowest PSV and 21%, be prepared for dysrhythmia and rapid deterioration of pt condition.
- KNOW when the Inotropes are off… these often have as great of an effect as vent support in how long a pt lives after.
- Don’t forget to minimize alarms.
Use of Drying Agents
Anticholinergics
Used to minimize secretions and ‘death rattle’.
Others listed will cross blood brain barrier but still have useful applications at end of life.
Scopolamine (Hyoscine) Hydrobromide
Trade Name: Transderm Scop
Route: Patch
Starting Dose: 1.5 mg
Onset/Duration: 12-24 Hours
Hyoscyamine
Trade Name: Levsin
Route: PO, SL
Starting Dose: 0.125 mg
Onset/Duration: 30 min
Glycopyrrolate
PO
Trade Name: Robinul
Route: PO
Starting Dose: 0.2 mg
Onset/Duration: 30 min
Glycopyrrolate
Sub Q, IV
Trade Name: Robinul
Route: Sub Q, IV
Starting Dose: 0.1 mg
Onset/Duration: 1 min
Glycopyrrolate Sub Q or IV has the most rapid onset of action.
Advantages of Glycopyrrolate
Glycopyrrolate does not cross Blood brain barrier and therefore are less likely to cause CNS toxicity such as blurred vision, sedation, confusion, delirium, restlessness, hallucinations.
Managing Family Expectation
Item 1: Make sure they don’t feel obligated!
Ask the family if they know what to expect or if anyone has explained what may happen.
Provide the right amount of information.
Explain how important the patient’s comfort is to you.
Use simple language - describe irregular breathing and gurgling (as normal), not agonal.
Offer the family an opportunity to participate in care: wash cloths, suction if appropriate.
Give the family permission to be at extubation, and to change their mind at any time
Your tone of voice/body language should be compassionate and understanding, but also confident.
Talk to the patient in gentle tones, use small gestures. Touching the patient can be very comforting to the family.
Showing your own emotions is okay! Express your condolences (no obligation but good to do).
Resuscitative Care
R1- Can do everything
R2- Cannot do chest compressions
R3- Cannot do chest compressions or intubate
Medical Care
you cannot do chest compressions or intubation
M1-Cannot resuscitate and will not go to the ICU
M2- Cannot resuscitate and will not go to the ICU and site transfer and surgery will only be used for symptom control
Comfort Care
Comfort Care will be focused on keeping pain to a minimum
C1- Cannot resuscitate and will not go to the ICU and site transfer and surgery will only be used for symptom control still has life sustaining measure as well as symptom control
C2- Will only be symptom control
