PCNOW Advocacy Alert #4
Guideline for Ventilator Removal

There comes a time for many critically ill patients when mechanical ventilation is no longer meeting a patient-centered goal; when the patient is dying, and removal of mechanical ventilation is the most appropriate procedure to alleviate suffering and honor patient/family wishes.   However, the steps taken to remove the ventilator and ensure patient and family comfort is often completed in a haphazard manner, resulting in preventable patient/family and staff suffering.

Best practice recommendations for ventilator withdrawal exist that respect the needs of patients, families and minimize any suffering/distress of the procedure.

PCNOW recommends that members assess the current practice for ventilator removal in your setting and help spur development of a written guideline to minimize clinical variation and reduce suffering.

Advocacy Steps

1. Reach out to both physician and nursing Intensive Care Unit leaders and ask if there is an existing written ventilator removal protocol. If present, ask if the protocol is routinely used and if there are any specific problems with applying the protocol in practice.
   • If you have been involved in sentinel case(s) where a bad outcome resulted from lack of a protocol, discuss that case with ICU leaders.
2. If there is a protocol that is poorly used or no protocol exists, ask if you can participate in a committee to develop a revised or new protocol. Suggest that membership of the committee should include ICU staff, Palliative Care staff, Pharmacy, and members of the Quality Improvement department.
3. Review the references listed below for best practice standards and sample protocols and seek out other resources.
4. Work to develop both a written protocol and a quality development process to ensure that the protocol is uniformly used and updated on a timely basis.

Resources

• Ventilator Weaning Protocol – Marshfield
• Ohio State Palliative Ventilator Withdrawal Protocol

References

• Fast Fact #33 – Ventilator Withdrawal Protocol
• Fast Fact #34 – Symptom Control for Ventilator Withdrawal in the Dying Patient
  
• Fast Fact #35. – Information for Patients and Families About Ventilator Withdrawal
• American Association of Critical Care Nurses-Ventilator Withdrawal Guidelines http://www.aacn.org/WD/Palliative/Docs/mgh8.pdf
• Campbell, ML, Yarandi, HN and Mendez M. A Two-Group Trial of a Terminal Ventilator Withdrawal Algorithm: Pilot Testing. J Pall Med 2015; 9: 781-784.