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Vol. 67, No. 1 2016
Northeast Florida Medicine
DCMS online
. org
Palliative Care
the patient would have chosen to accept.
2
Every now and
then, patients get intubated because their DNR (do not
resuscitate) order could not be located at the time of intu-
bation. If it later surfaces in the intensive care unit (ICU),
the family can ask for extubation.
It is critical to the success of a “good death” to have a
candid conversation with the family members, so they can
understand the medical facts. Not infrequently, a physi-
cian can use the speaker phone on the family member’s
cell phone to include other crucial family members in the
decision making process. A physician should also make a
concerted effort to get the perspective and opinion of the
relevant specialists before approaching the family, so the
entire medical team is on the same page. The family needs
to hear a consistent message from that team.
It is important to use language that lay people can relate
to- often at a fifth grade level. Frequently, amongst the
family there is a member with a medical background. In
these cases a physician should address that person individ-
ually, using medical language that will be understood. This
‘medical’ family member can be very helpful in getting a
consensus in the family, as a whole. Although a consensus
amongst family members is preferable, it is not crucial, as
long as the wish of the surrogate or proxy, is followed. This
is predicated on the patient’s wishes regarding end of life
care. Often it takes more than one conversation with the
family to make a decision. Sometimes it takes more than
one physician to reiterate the poor prognosis for the family
to come to a decision that they are comfortable with. In the
rare instance, the decision is made to not take the patient
off life sustaining measures. In those cases, the patient
undergoes a tracheostomy and insertion of a percutaneous
endoscopic gastrostomy (PEG), and is transferred to a long
term acute facility for further care.
It is imperative that the family is informed of the pro-
cedure in detail for the terminal wean and be allowed to
ask questions that will set their minds at ease. It is equally
important to inform them of possible outcomes after ex-
tubation. A physician should tell them that one of three
possibilities will occur: i) the patient may pass very soon
(minutes to hours) after extubation, ii) the patient may
linger for several days, iii) rarely, the patient may recover to
the extent that they may be well enough to be discharged
to a long term facility. The family should be prepared for
Introduction
Palliative care physicians are often asked if their work is
depressing with the implication that it probably is. However,
the satisfaction of facilitating a “good death” for patients,
by reducing suffering and receiving the gratitude of their
families, is reward enough. One form of “good death”
is the compassionate terminal wean. The withdrawal of
life-sustaining measures is a clinical procedure, and as such,
deserves the same preparation and expectation of quality
as other procedures.
1
After the decision to withdraw life
support is made, a protocol for removing the patient off
the ventilator is critical.
A successful terminal wean would not be possible without
other members of the palliative care team, who are critical
to its success. Depending on the setting, these team mem-
bers include physician colleagues, nurses, social workers,
respiratory techs, and last but not least, members of the
clergy. These individuals are vital to the ease and comfort
of the patient and family. They are also a source of support
for each other. It can be, and often is, an emotionally
exhausting experience for everyone involved.
End of Life Conversation
The decision to withdraw life sustaining measures, in-
cluding the ventilator, is never taken lightly. It is made in
conjunction with the family when there is little chance of
meaningful recovery. This is also true in instances when
continuing to ventilate the patient serves to prolong the
dying process or when the quality of life would be unac-
ceptable to the patient, even if the individual was to be
successfully weaned of the ventilator. The conversation
is also prompted when prior attempts at weaning have
failed; in cases of futility, or when the family decides that
continuing ventilation in such circumstances is not what
Compassionate Terminal Weaning: Putting an End to Suffering
By Neel Karnani, MD, FAAFP, FAAHPM
Palliative Care Service, Orange Park Medical Center, St. Vincent’s Clay County
Medical Director, Haven Hospice, Orange Park, FL
Address Correspondence to:
Neel Karnani, MD
Haven Hospice
741 Blanding Boulevard
Orange Park, FL 32065