Terminal Extubation: Discussion and Protocol By Bernard Freedman, Bioethicist
Transparency:
The salient ethical, moral and principle necessity to terminal extubation is the transparency of the conduct of all physicians and medical staff, and fundamental understanding by the patient family and or friends as to why it is being done and how it is being done. It is therefore the obligation of the primary treating physician (PMD) to assure full communication and full documentation.
All must keep in mind that the critical distinguishing factor between terminal extubation and physicians assisted suicide is the patient’s rejection (by the patient of patient's surrogate) of artificial life sustaining treatment followed by the alleviation of pain and discomfort of the dying patient. Unambiguous documentation must avoid any appearance of physician assisted suicide. Only by being forthright about these factors can real transparency exist.
It is the fundamental right of all patients to reject medical treatment after all risks have been explained and all options presented. It is this rejection of treatment by a patient that distinguishes the act of caring for the patient from assisting in a patient’s suicide. The principle of the “double effect” in the use of elevating doses of opioids that may depress the respiratory system that is intended to diminish or alleviate the patient’s pain is not considered assisting the patient to end their life. Although ordering of opioids may hasten death it is the intention of alleviating pain after and only after, the patient’s refusal of life sustaining treatment. After a patient is extubated, the goal of medical care must shift to the treatment of symptoms.
Families will receive complete explanations that death will occur after an unknown period of time after extubation. Whether a family should be present during terminal extubation may depend upon their complete understanding and acceptance of the act and its consequences. It is generally best to have family and friends leave the room at the time of extubation.
Protocol:
1. Terminal extubation can only be performed after a collective decision-making process. It should be discussed by a group, for example, Primary Treating Physician and any of the following; Consulting Pulmonologist; Respiratory Therapist; Bioethicist; Nursing Director of Critical Care; and Critical Care Nurses involved in the patient’s care.
2. If possible, at least a 24-hours period should pass from the time of the decision to the time of extubation. If a surrogate has made the decision, the surrogate must review, understand, sign and have witnessed a Form for Withdrawal of Treatment. It is wise to offer the opportunity for the surrogate decision maker to meet with clergy. In light of the recent case law it is appropriate to ask the surrogate decision maker if there is someone in the family who is objecting to the terminal extubation. This will serve to protect the patient life as well as the physicians and hospital from potential liability for terminally extubation of the patient when a family member is objecting. If this cannot be worked out court assistance may be necessary for the protection of all concerned. (A sample form is included below).
3. The PMD should personally perform or supervise terminal extubation. Involvement of the PMD reflects the importance of end-of-life care and sensitivity to the family. Terminal extubation therefore should not be seen or conducted as an everyday medical procedure. The PMD must be sensitive in providing any cultural or spiritual factors needed to allow the utmost respect and dignity to the patient, family and friends.
4. NOTE: Patients who are in a minimally conscious state or have a non-terminal illness will require the Ethics Committee to meet and confer directly with the PMD and relevant consultants and review all necessary medical records before a decision to terminally extubate may be made. In this regard the PMD and Ethics Committee must determine that there is clear and convincing evidence that the patient would reject artificial life sustaining treatment under the medical circumstances existent at that time. All family and friends who can be reasonably located will receive notice of the intent to terminally extubate and given at least 24 hours to object. If there is any objection, risk management and legal counsel will be consulted immediately.
Notification of Death
Notification of death should be delivered in person, whenever possible by the PMD. The family frequently must be contacted by telephone if they are not present at the time of death. Family notification may be accomplished by any physician or nursing staff and should be documented.
For an excellent discussion, see: http://www.google.com/search?client=firefox-a&rls=org.mozilla%3Aen-US%3Aofficial&channel=s&hl=en&source=hp&q=www.ethics.va.gov%2F...%2FNET_Topic_20050330_Terminal_Extubation.doc&btnG=Google+Search
Bernard W Freedman, Bioethicist
Exemplar Form
Withdrawal or Withholding of Life Sustaining Treatment Form: (2 pages)
Name of Patient: ___________________________________________
Date of Birth of Patient: _____________________________________
Social Security Number: _____________________________________
Medical Identification Number: _______________________
I, _______________________________, am the Surrogate Medical Decision Maker for_______________________________, (patient). I have met with the primary physician, _________________________M.D. and discussed the patient’s medical condition and prognosis. I have been advised that continued medical treatment will not improve the prognosis for recovery; will result in unnecessary pain and suffering and medically unnecessarily prolonging death.
I have been offered the opportunity to speak with other physicians who have participated in the care of the patient, if any, and/or to have a second opinion from another physician of my choice, or by a physician provided for me.
I have been offered the opportunity to discuss this decision with a Bioethics Consultant and/or to have this decision reviewed by the Medical Center Ethics Committee. I have also been urged to speak with clergy, other family members, and close friends, in order to discuss the wishes of the patient, and to consider any cultural and religious values.
After carefully considering all information I have determined that the patient would not want to continue to receive and/or accept life sustaining treatment. I have also determined that withholding and/or withdrawing life-sustaining treatment is in the patient’s best interest. I am not aware of any person who is objecting to this decision.
I hereby request and authorize the withholding and/or withdrawing of the following artificial life sustaining measures, while continuing with all appropriate palliative care for the patient: ________________________________________________________________________________________________________________________________________________
Name of Surrogate: ______________________________
Relationship to Patient: ___________________________
Signature: ________________________ Date: _____________
Witnessed By:
Name: _______________________,
Signature: ________________________ Date: _____________
Name of Primary Physician*: ____________________________,
Signature: ________________________ Date: _____________
Witnessed By:
Name: _______________________,
Signature: ________________________ Date: _____________
*“Primary physician" means a physician designated by a patient or the patient's agent, conservator, or surrogate, to have primary responsibility for the patient's health care or, in the absence of a designation or if the designated physician is not reasonably available or declines to act as primary physician, a physician who undertakes the responsibility.
Bernard W. Freedman, J.D.,M.P.H. is an attorney at law and an active member of the California State Bar since 1976. (State Bar number 70888). He has specialized in medical legal law and acted as consultant in clinical bioethics and...