3D – A Team Approach to Ventilator Withdrawal in the Home

Speaker(s): Emily Black, APRN, CNP; Maureen Bigelow, RN, BSN

The integration of palliative care into the home that would otherwise typically be performed in the hospital empowers patients and families by allowing for more choices when facing difficult end of life decisions. Compassionate extubation, also known as palliative extubation, is the withdrawal of mechanical ventilation. This is performed to alleviate suffering while avoiding the prolongation of death. Compassionate extubation in a non-ICU setting requires seamless collaboration amongst the interdisciplinary team. The logistics of such a process generally requires an inpatient setting. This presentation will highlight two cases recently completed by the Mayo Clinic Hospice team. In the case of a 27 year old patient with cerebral palsy, multiple medical complications resulted in ventilator dependence and a subsequent decline in quality of life, ultimately prompting hospice enrollment. Additionally, in the case of a 62 year old patient with ALS, severe debility resulting in poor quality of life led him and his family to chose to withdraw ventilatory support. Discussion surrounding end-of-life issues, particularly involving the withdrawal of mechanical ventilation, can be especially difficult if the patient’s family are in unfamiliar surroundings. In an effort to meet goals for care to remain at home, the Mayo Clinic Hospice team formulated a procedural guideline to facilitate the process of ventilator withdrawal in the home, including detailed plan in anticipation of symptom management. Through collaboration with physicians, nurse practitioners, nurses, pharmacists, respiratory therapists, social workers and home infusion specialists, both patients were removed from mechanical ventilation and died peacefully at home surrounded by loved ones. This outcome resulted in an high level of satisfaction for the families and helped bring peace as they began the journey through grieving the loss of their loved one. Team debriefing after the cases contributed to further refinement of the process.

Upon completion of the activity, learners will be able to:

• Identify the interdisciplinary team members necessary to complete withdrawal of ventilator support in the home.

• Describe a sample protocol for withdrawal of ventilator support.

• Describe key components for symptom management immediately following ventilator withdrawal.