The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 6: Pulmonary SymptomsDiscontinuation of VentilatorsVentilator-dependent patients, or their designated decisionmakers, sometimes choose to stopventilator26 picassupport once it has been initiated. They may decide that the quality of life associatedwith ventilator dependency is not acceptable or they may no longer desire life-prolonging interventions.These are reasonable choices and are ethically acceptable to most people based on thepremise that discontinuation of an intervention that artificially prolongs life is not differentfrom choosing to forego the treatment in the first place.It is essential to be certain that the decisionmakers and others who care about the patientunderstand clearly that the expected outcome of discontinuing ventilation is death. The possibleprocesses leading to death, such as immediate cessation of breathing or a more prolongedperiod of gradual respiratory failure, should be explained, when appropriate.Once decisions have been finalized, a specific time can be set for discontinuing ventilation.There are advantages to allowing all participants to have time to review the decision and “sleepon it” by scheduling the procedure for the next day or later. Support for family and friends bychaplains, social workers, or others can be planned in advance. The patient should be placed inan area that offers privacy and space for all family and friends who need to be present. It isimportant to allow, even encourage, rituals that have meaning for the patient and family, such asprayers, readings or singing. The specific details of such plans depend on the beliefs and cultureof those who will be present.Plans for the use of supplemental oxygen should be considered before terminating ventilatorsupport. If oxygen supplementation will be stopped, it is often helpful to titrate concentrationsdown to room air before discontinuing the ventilator. If it will be continued, then the concentrationshould be reduced to levels easily supported by a simple mask (35% to 50%) or a nasalcannula (30% to 35%).The process of discontinuation of mechanical ventilation is simple and usually uneventful. Patientscan be prepared with intravenous access and sedated, if necessary, with intravenousmidazolam or lorazepam. It is difficult to imagine any circumstances where paralytic agentswould be appropriate during discontinuation of the ventilator. Once sedated, intravenous morphine(starting with 2 to 4 mg if opioid-naïve) can be titrated to suppress the sensation of dyspnea,and tracheal suctioning may be done one final time.The ventilator can then be disconnected at the endotracheal tube, replaced by a blow-by circuit,or switched to a ventilator mode with no positive pressure ventilation. Alarms should be silencedand unnecessary monitoring devices removed.If an endotracheal (ET) tube is in place, there is often a desire to extubate the patient at thetime of discontinuing the ventilator. Again, this decision should be carefully considered in advance.Extubation provides a more normal appearance for the patient, removes the resistanceassociated with breathing through a tube, and may allow the patient to talk. However, suctioningand airway protection will be more difficult without the tube in place.Some patients occasionally have a reflex laryngospasm from the irritation of the ET tube when itis removed and are unable to breathe. While this symptom can be treated with rapidadministration of additional intravenous midazolam or morphine, it may be alarming to friendsand family. The development of agonal respiration and “death rattle” may also be distressing toobservers and is more easily managed with suction available through the ET tube. The decisions140U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau