Pacific Coast Hospice Palliative Extubation Program

Modeled by the Center to Advance Palliative Care (CAPC)

The goal of withdrawing life-sustaining treatments is to discontinue therapies that are no longer desired or no longer providing comfort to patients. If not appropriately treated, patients who die after the withdrawal of mechanical ventilation can experience pain, dyspnea, and other distressing symptoms. Family members witnessing this may experience complicated grief after the patient’s death. Our goal as a Hospice provider is to relieve suffering and not to hasten death. Withdrawing life-sustaining treatment is a medical procedure that requires the same degree of Physician participation and quality assurance as any other medical procedure.

Withdrawing life-sustaining treatment is morally and legally equivalent to withdrawing treatment. Any treatment can be withdrawn or withheld, including nutrition, fluids, antibiotics, or blood products.

In line with the Hospice multidisciplinary approach, a team is setup consisting of a Hospice Physician, Hospice Nurse and/or Nurse Practitioner, and Hospice Social Worker. Upon referral to the Palliative Extubation Program, Pacific Coast Hospice will implement the steps necessary for discontinuation of therapy.

Step 1 — Discussion and Documentation

  1. Discussions will commence regarding prognosis, options, and goals of care with the patient, surrogates, and family. Palliative Extubation is appropriate if a consensus has been reached to remove mechanical ventilation with expected death as the optimal treatment course. Medical Documentation is required to support treatment.
  2. Pacific Coast Hospice will lead a discussion regarding the process of withdrawing mechanical ventilation and the expectations of the dying process. Our discussion will focus on comfort, including the discontinuation of routine vitals, labs, and non-comfort medications.
  3. Adequate communication between Health Care Providers, Physicians, appropriate consultants, nursing and other staff is essential.

Step 2 — Establish Time Frame & Begin Preparation

  1. Pacific Coast Hospice will establish a timeframe with the family and Hospital staff for proceeding with Removal of Mechanical Ventilation (RMV). Hospice Staff will be notified and asked to be present at the established time.
  2. When Mechanical Ventilation is withdrawn, patients may experience a sudden increase in dyspnea. Strong consideration is given to increasing sedative medications prior to and immediately after removing mechanical ventilation. Pacific Coast Hospice will arrange for delivery of medications that will be used, including additional medication that may be needed at the bedside.

Step 3 — Removal of Mechanical Ventilation

  1. Pacific Coast Hospice will ensure adequate sedation of patient.
  2. The Hospice Physician and/or Nurse will prepare space at bedside for patient and family members.
  3. The Hospice Nurse will silence alarms and Physician will remove ventilation per protocol.
  4. The patient will be observed for signs of distress and adjust medications as necessary for comfort.

Step 4 — After Care

  1. The Hospice Nurse will pronounce the patient and implement after care procedures.
  2. Cultural and religious views of the patient and family members are considered..
  3. The assistance of a Spiritual Care Provider, Social Worker, and bereavement services are offered as appropriate.

We recognize that this is a very stressful, challenging time and we offer our support to you and your loved ones. If you require assistance under our Palliative Extubation Program, please contact our office directly.