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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 24: Medical Care at the End of Lifeventilator support is to remove a treatment that is no longer desired or does not provide comfort to thepatient. Clinicians need to work to develop a consensus among the health care team in order towithdraw ventilatory support; it is seldom an emergency decision, and time should be taken to resolvedisagreements26 picasand concerns among the team and family. This procedure requires informed consentdiscussions, especially to inform family members that patients may not die immediately afterventilation is withdrawn.A protocol developed by experienced critical care physicians appears in Table 24-5.Table 24-5: Protocol for Ventilator Withdrawal at End of LifeStepSpecific ActionsPrepare the family and Hear concerns, address fears, establish informed consent,patient (if conscious)explain procedure so they are prepared, give family a place atthe patient’s bedside if they wish.Appropriate setting and Provide privacy to the greatest degree possible in the ICUmonitoringsetting. Turn off all monitors. Remove tubes, drains, andassociated machinery if possible without compromisingcomfort. Liberalize visitation as much as possible.Ensure adequate sedation Establish continuous infusions of analgesia and antianxietymedications; provide wide latitude in drug dosing to nurseswho have experience in evaluating suffering in patients whocannot talk.Reduce inspired oxygen to This should be done in steps, with adequate time to ensure21% (air) that any dyspnea or air hunger is controlled with themorphine infusion; if the infusion is increased, bolus dosesshould be given to rapidly establish the new steady state.Remove positive endAir hunger must be relieved before proceeding with morphine.expiratory pressure (PEEP)Set ventilator to IMV or This provides another period to establish patient comfortPS level to fully meetbefore proceeding.patient’s ventilatory needsObserve and modifyThis process may take 15 to 30 minutes. Family may wish tosedatives while gradually be present, but should be warned of the possibility of transientreducing IMV rate or PS increases in agitation or respiratory rate as sedation is beinglevel to 5titrated. Ventilator alarms must be disabled so they are nottriggered by terminal hypoventilation.Extubate or leave onOffer the family the possibility of private time with the patienthumidified air by T-piece if feasible, or support from any staff members they wish tohave present. Rituals devised by the family or performed byclergy may have an important role.XXIVU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 501