Experiences of palliative weaning and extubation among intensive care clinicians

Summary

Background

Most deaths in intensive care units (ICUs) occur after a decision to either withhold or withdraw life-sustaining measures (WLSM) such as mechanical ventilation [1,2]. Mechanical ventilation withdrawal may be implemented either gradually (palliative weaning) or in a single step (palliative extubation) [3,4]. Both methods are practised globally since there is limited evidence to suggest the superiority of either method, although palliative extubation provides a non-medicalised death, whereas palliative weaning may delay unnecessary the dying process.We lack any real knowledge or insight to the factors at play to influence choices, when and how the views of colleagues and/or family members are invited to decide, and how decisions are justified, communicated and operationalised.

Aim/objectives

To explore experiences of palliative weaning and palliative extubation among ICU clinicians.To identify the incidence of palliative weaning and palliative extubation and related actions during the withdrawal of life-sustaining measures for a period of a year.

Methods

• Descriptive qualitative research
• Retrospective chart reviews

Results

The following themes were identified by two of the three study sites.

USA: Fine-tuning the Process of TWMV; Focusing on the Family; Ensuring Patient-Centered Care; Impact on Healthcare.

UK: Multi-layered communication; Mode of withdrawing invasive mechanical ventilation; Multi-professional teamwork; Clinicians’ feelings and impact.

Conclusion, implications and impact

When withholding/withdrawing life sustaining treatments in ICUs, there is a need for clear communication of a palliative withdrawal of mechanical ventilation plan between ICU clinicians to avoid conflict during the process, ensuring medication is in place for potential distressing symptoms, incorporating patient and family wishes in planning, supporting the family during the process, and training and support for clinicians.

Future plans

• Analysis of qualitative data from Canada. 
• Analysis of incidence of palliative weaning and palliative extubation and related actions during the withdrawal of life-sustaining measures.
• Synthesis and comparison of data from the three sites.

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We would like to invite researchers who would be interested to investigate palliative withdrawal of mechanical ventilation in other countries.

Outputs 

1. Orr, S., Efstathiou, N., Baernholdt, M., & Vanderspank-Wright, B. (2022). ICU Clinicians' Experiences of Terminal Weaning and Extubation. Journal of pain and symptom management, 63(5), e521–e528. https://doi.org/10.1016/j.jpainsymman.2022.01.016.