Picture this patient: She is 86, in respiratory distress. Her nursing home calls EMS, who find the patient has thready pulses, then no pulse. They start CPR and intubate the patient in the ambulance. Spontaneous circulation returns en route to the ED.
A central line is placed, and labs are drawn. She exhibits no purposeful movements, does not respond to her family or the physicians, and remains completely dependent on the ventilator. The next move is usually to admit her to the ICU. But you have a problem: The patient's daughter appears in the ED distressed. She tells you that her mother would never have wanted this. Her code status is “do not attempt resuscitation/do not intubate” (DNAR/DNI), but that information was never relayed to EMS.
The family's distress grows — they realize their mother is suffering, but they don't know how to stop the barrage of tests and interventions. Five days later, the medical team acknowledges what the family already knows: The patient will not improve. Options are discussed, and the daughter, exhausted and tormented, decides on palliative extubation.
This is a grim picture. One that may be extreme, but one that is not out of the ordinary.
Let's talk about palliative extubation. Yes, in the ED, and yes, by you. Palliative extubation, also known as compassionate extubation, is the removal of the endotracheal tube from a patient who is not expected to sustain independent respirations while easing the patient's suffering. (Clin Interv Aging 2015;10:679.) The procedure is intended to provide a patient with comfort and freedom from the ventilator with the understanding that the goal is quality of life, not quantity of life.
This is certainly something that can and should be carried out in the ED. The goal of care is clear: This patient would not have wanted her death to be like this. Reversing this procedure in the ED would be honoring this patient's wishes, avoiding prolonged, unnecessary physical and emotional suffering, and offering the family some peace during this difficult time. An ICU admission may be avoided, and if necessary, a private bed in the ED or the floors would offer the patient and family some quiet respite in the patient's last moments.
How do you carry this out in the ED?
Sit down with the family to review what happened. It is certainly not your fault, but it should not have happened, so apologize to them. Then suggest a plan: “I understand your mother would not have wanted this if her heart were to stop. Unfortunately, the medics did not receive this information. Her heart did stop, but due to the medications and our interventions, they were able to regain a pulse. Now she is on the ventilator with a prognosis that is very guarded. There are some options. One is to take the breathing tube out. We would give her medications so that she is not in pain and does not experience any distress. This way, we could acknowledge her wishes and allow for a natural death. The other options are to....”
This is typically followed by a family member saying, “But she's alive now!” This is a tough one. Her cardiac function has returned, but it came at the cost of a procedure that she had not wanted. She is left in a position that may not be acceptable in quality of life and suffering. You will have to explore this with the family, ask about the patient's values and thoughts about the end of life, and then guide them through the next steps and make a recommendation. It may be to proceed with palliative extubation.
Another common question is how long she will live after the tube is removed. It is often difficult to predict, but this is best answered with a time frame. I typically inform families that death is expected within hours to days following extubation.
Discontinue all unnecessary medications, IV infusions, enteral feeds, planned lab tests, and imaging, and then complete the necessary DNR/DNI paperwork. Document the rationale for withdrawing life-sustaining treatments and the discussions with the family. Place the patient in a private room if possible. Turn off the monitors and remove cuffs and monitoring devices. Remove NG tubes and unnecessary lines if they are potentially painful or problematic. Ask the family if they want to be present, and offer any available resources that may help them, such as a hospital chaplain or a social worker. Liberalize visitation, and communicate the plan to nurses, respiratory therapists, residents, and other personnel so that everyone is on the same page.
Medications can manage the symptoms of dyspnea or pain. Look for nonverbal cues for pain such as grimacing, furrowing of eyebrows, or teeth clenching. Ensure that the patient is not on paralytics that would mask symptoms. Start morphine 5 mg/hr continuous infusion or fentanyl 25 mcg/hr continuous infusion to manage pain and dyspnea. If symptoms are persistent, give a bolus equal to the set hourly infusion dose and increase the infusion rate by 25 to 50 percent. Repeat upward titration every 10 minutes as needed. If an anxiolytic is necessary, start lorazepam 2 mg IVP or midazolam 2 mg IVP every 10 minutes as needed to control anxiety. Start glycopyrrolate 0.1-0.2 mg IV every four hours to reduce oral secretions.
Remove the Tube
Reduce alarm settings to minimal or turn them off if possible. Once the patient seems comfortable, reduce FiO2 to 21% and reduce PEEP to zero in less than five minutes. Reassess the patient, and titrate medications to control symptoms. Reduce the respiratory rate and tidal volume to zero in less than five minutes. Reassess the patient, and titrate the medications to control symptoms. Then deflate the cuff and remove the ET tube. Have a towel or chuck available as copious secretions may be present. Place a humidified face mask on the patient for comfort. If death does not occur within three hours, admission is reasonable.
Conversations with elderly patients now focus more on living with quality and dying with dignity, making systemic gaps in communication and information transmission about DNRs and end-of-life decisions more evident. (J Gen Intern Med 2011;26:791.) These gaps are being addressed, but until these concepts become ingrained in our health care culture, emergency departments will continue to serve as the point of first encounter for these situations. (J Emerg Nurs 2006;32:101.)