The Johns Hopkins Hospital
Medical Nursing Service Standards of Care Manual
PROCEDURE FOR WITHDRAWAL OF LIFE SUPPORT
IN THE MICU/MCP
Policy
Number
450
Effective
Date
1/22/01
Supercedes
1/09/01
Definition:
Withdrawal of life support is defined as withdrawal of ventilatory
support with or without extubation and withdrawal or foregoing of
additional life sustaining treatments such as: cardiopulmonary
resuscitation, vasopressors, blood products, hemodialysis, nutrition,
antibiotics; thus allowing natural death to occur from the patient’s
underlying disease process.
Purpose:
To facilitate management and comfort care during the withdrawal
process, for patients who are not to be organ donors. This policy will be
applicable to patients who are DNR or so designated as part of the
implementation of this procedure. It shall apply to patients who are
intubated and on mechanical ventilation who are either:
a. Experiencing an irreversible terminal illness in
whom life support is postponing an unavoidable
death (see also JHH Interdisciplinary Clinical
Practice Manual Policy #MEL004, "Medically
Ineffective or Futile Treatment").
b. Those whose best anticipated outcome from
continued care is a state of health inconsistent with
the patient’s wishes as documented in the medical
record or understood by their family or surrogate
decision maker.
1.0 Responsibility:
1.1 The attending physician or fellow is responsible for decisions
regarding withdrawal of life support and must be directly involved,
prior to implementation of these procedures. Discussions with the
patient/surrogate related to withdrawal of life support will be
documented in the medical record by the attending or designee (see
2.1.1).
1.2 The MICU/MCP will adhere to the following guidelines when
sedation/analgesia are used in conjunction with withdrawal of life
support in the MICU.
2.0 Procedure:
2.1 Discuss plan for withdrawal of life support with the multidisciplinary team.
2.1.1 The MICU attending will discuss plans with
patient (for patients who are conscious and possess
decision-making capacity), family or
surrogate/guardian. There may be unusual
circumstances when this discussion with the patient
or surrogate cannot be held by the MICU attending.
For example, important family members may arrive
late at night or the patient might precipitously
deteriorate when the attending or fellow are out of the
hospital. In such cases, it may not be in the patient’s
best interest to delay the withdrawal of care until the
attending can be present. In these circumstances, the
discussion with the patient or their family regarding
withdrawal of life support may be held by the MICU
resident, but only after consultation with the MICU
attending by phone. The attending or designee shall
document the conversation, including the element of
consent, in the patient’s medical chart.
2.1.1.1 Family conference with
family members, nursing,
physicians, and other multidisciplinary team members as
needed, (i.e., chaplain, social work,
respiratory therapy).
2.1.1.2 Consult Palliative Care
Team, Ethics Committee and Legal
Department as needed (e.g., for
conflict resolution, see JHH
Interdisciplinary Clinical Practice
Manual Policy #MEL004,
‘Medically Ineffective or Futile
Treatment’).
2.1.1.3 Direct caregivers (RN or
clinical technician) assigned to
patient should be comfortable with
withdrawal process. If not, attempts
should be made to change staff
member’s assignment. See Human
Resources Policy and Procedure
Manual Policy #ELR610, ‘Staff
Requests Not To Participate in
Patient Care".
2.1.2 Determine if Pastoral Care needs to be present
for patient and family support before and/or during
withdrawal of life support.
2.1.3 Prepare patient and family for what may occur
during withdrawal of life support such as comfort
measures of sedation and analgesics that may be
given, presence of increased respiratory effort with
eventual decline, heart rate variation, decreasing
blood pressure, periods of restlessness, and/or skin
color changes that may occur. (See Appendix A for
more information).
2.1.4 Discuss who needs or wants to be present from
family and coordinate timing so that withdrawal will
begin when appropriate individuals are present.
2.2 Obtain order for analgesia and sedation utilizing MICU Orderset for
Withdrawal of Life Support. Patients who have experienced adverse
reactions to either Fentanyl or Ativan, will be ordered pain/sedation
agents based on physician judgement. The RN will confirm that
attending physician has signed orderset or has discussed orderset with
resident or fellow. This is accomplished by checking the progress notes
for documentation of conversation with attending. Documentation must
be present prior to initiating this policy. Confirm DNR status. Follow
orderset to indicate treatments and interventions to be discontinued, if
desired.
2.2.1 Initiation and/or continuation of neuromuscular
blockade (e.g. pavulon, succinylcholine) is prohibited
during the withdrawal of life support.
2.3 Notify Respiratory Therapy that withdrawal of mechanical
ventilation is ordered and the possible time frame.
2.4 The physician should discuss the manner and goals of palliative
care with the patient and family to determine their desire for analgesia,
sedation, or both and then indicate level of sedation desired prior to the
withdrawal of life support in the Orderset. Level of Sedation:
O = No response
1 = Responds to deep pain only
2 = Drowsy, but hard to arouse; needs tactile stimuli
3 = Drowsy, but will open eyes when name called several times.
4 = Drowsy, but easily aroused, opens eyes when name called.
5 = Awake, oriented x3, or may be delirious, agitated, expressing pain.
2.5 Once patient is sedated to the ordered sedation level and family is
ready for withdrawal to occur, notify the respiratory therapist. The
respiratory therapist will extubate the patient to room air or per
physician’s order (based on an individualized assessment of the
particular patient, the physician may choose to gradually decrease
ventilatory support, or extubate to oxygen, humidified room air or place
on t-piece). The respiratory therapist will document on the ventilator
flow sheet the method and time of withdrawal.
2.5.1 If the respiratory therapist requests not to
participate in the extubation of the patient, the
extubation may be performed by the physician or
nursing staff, with respiratory therapist in attendance
(see Human Resources Policy and Procedure Manual
Policy #ELR610, "Staff Requests Not To Participate
in Patient Care".
2.6 Monitor the patient continuously for signs of discomfort and
distress and administer additional sedative/pain medication per orderset
as needed for comfort, unless the physician provides alternative orders.
Do not withhold medication for comfort if the patient becomes
hypotensive, bradycardic, or there is a decrease in the level of
consciousness. Signs that indicate discomfort and/or distress are:
2.6.1 Moderate to severe use of accessory muscles.
2.6.2 Respiratory rate exceeding 35/minute.
2.6.3 Gasping, noisy and/or increased respiratory
effort, coughing or choking.
2.6.4 Increased agitation, unnecessary movement of
head, legs, torso, or facial grimacing.
2.6.5 Increased heart rate or mean arterial pressure
more than 20% above the level prior to withdrawal of
life support, before or after sedation.
2.7 The RN will document the time the withdrawal process was
initiated and the sedation level prior to withdrawal in the vital sign
section of the nursing flowsheet. Document the rationale (as listed in
2.6) for administering additional sedation or analgesics in the nurse’s
notes section. This should occur with all doses or drip changes given
for the comfort of the patient after withdrawal of life support.
2.8 Cardiac monitoring display in the patient’s room may be
discontinued during the withdrawal process based on the discretion of
the health care team or as requested by family.
2.9 Once patient has died, allow the family time with the patient.
Remove all equipment and tubes, unless otherwise indicated (i.e.,
autopsy).
2.10 Allow time for staff member caring for patient and other members
of the health care team to express their feelings [after patient’s death]
as a debriefing event.
2.11 If the surrogate decision-maker reconsiders withdrawal of life
support, hold current settings of sedatives/analgesics (do not increase
titration), notify physician immediately, and prepare to reinitiate life
support and readdress code status.
See Also:
Do Not Resuscitate Policy, Interdisciplinary Clinical
Practice Manual, PAT005.
Medically Ineffective or Futile Treatment,
Interdisciplinary Clinical Practice Manual, MEL 004.
Staff Requests Not to Participate in Patient Care,
Human Resource Policy and Procedure Manual, ELR
610.
Education: All MICU attendings and fellows will be informed of and trained in this
policy by the MICU Medical Director. Housestaff will be instructed in the policy as
needed (i.e., when the policy is to be invoked on a specific patient). Nurse Manager or
designee will be responsible to train nursing staff.
Reviewed by:
Dr. Roy Brower, Dr. Henry Fessler (MICU Attending Physicians)
Risk Management
Medical Staff Risk Management Committee
Administrative Committee of the Medical Board
Medical Care Evaluation Committee
Critical Care Committee
Ethics Committee
Medical Board
References:
Campbell, Margaret, C., 1998, Forgoing Life-Sustaining Therapy, How
to Care for the Patient Who is Near Death.
Daly, B., Thomas, D., and Dyer, M.A., Procedures Used in Withdrawal
of Mechanical Ventilation. American Journal of Critical Care, 1996,
5(5), 331-338.
THE JOHNS HOPKINS
MEDICAL NURSING SERVICE STANDARDS OF CARE MANUAL
ORIGINAL: 2/00
1/22/01 DRAFT 12
Revised: 3/00, 5/00, 7/6/00, 8/28/00, 10/3/00, 10/11/00, 11/30/00, 1/9/01 ,