Withdrawal of Mechanical Ventilation in the Neonate/ Pediatric Patient
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Withdrawal of Mechanical Ventilation in the Neonate/ Pediatric Patient
The process of mechanical ventilation is considered as a key method of innovative life sustenance in the Emergency Unit ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"p5FG6h3w","properties":{"formattedCitation":"(Munson, 2007)","plainCitation":"(Munson, 2007)","noteIndex":0},"citationItems":[{"id":461,"uris":["http://zotero.org/users/local/CKNkWnK9/items/2SBWBF4W"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/2SBWBF4W"],"itemData":{"id":461,"type":"article-journal","container-title":"Pediatric Clinics of North America","DOI":"10.1016/j.pcl.2007.08.001","ISSN":"00313955","issue":"5","journalAbbreviation":"Pediatric Clinics of North America","language":"en","page":"773-785","source":"DOI.org (Crossref)","title":"Withdrawal of Mechanical Ventilation in Pediatric and Neonatal Intensive Care Units","volume":"54","author":[{"family":"Munson","given":"David"}],"issued":{"date-parts":[["2007",10]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Munson, 2007). However, some extremely ill patients that receive mechanical ventilation recover successfully. Several others either die still using it or they are ultimately left to wait for their death by withdrawing the process of mechanical ventilation. In a medical setting, withdrawal of this form of sustenance is a usual practice which leaves patient expecting his death ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"sWje0EBT","properties":{"formattedCitation":"(Burns et al., 2000)","plainCitation":"(Burns et al., 2000)","noteIndex":0},"citationItems":[{"id":468,"uris":["http://zotero.org/users/local/CKNkWnK9/items/32NQU9MV"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/32NQU9MV"],"itemData":{"id":468,"type":"article-journal","abstract":"OBJECTIVE: To describe the attitudes and practice of clinicians in providing sedation and analgesia to dying patients as life-sustaining treatment is withdrawn.\nSTUDY DESIGN: Prospective case series of 53 consecutive patients who died after the withdrawal of life-sustaining treatment in the pediatric intensive care unit at three teaching hospitals in Boston. Data on the reasons why medications were given were obtained from a self-administered anonymous questionnaire completed by the critical care physician and nurse for each case. Data on what medications were given were obtained from a review of the medical record.\nRESULTS: Sedatives and/or analgesics were administered to 47 (89%) patients who died after the withdrawal of life-sustaining treatment. Patients who were comatose were less likely to receive these medications. Physicians and nurses cited treatment of pain, anxiety, and air hunger as the most common reasons, and hastening death as the least common reason, for administration of these medications. Hastening death was viewed as an \"acceptable, unintended side effect\" of terminal care by 91% of physician-nurse matched pairs. The mean dose of sedatives and analgesics administered nearly doubled as life-support was withdrawn, and the degree of escalation in dose did not correlate with clinician's views on hastening death.\nCONCLUSION: Clinicians frequently escalate the dose of sedatives or analgesics to dying patients as life-sustaining treatment is withdrawn, citing patient-centered reasons as their principle justification. Hastening death is seen as an unintended consequence of appropriate care. A large majority of physicians and nurses agreed with patient management and were satisfied with the care provided. Care of the dying patient after the forgoing of life-sustaining treatment remains underanalyzed and needs more rigorous examination by the critical care community.","container-title":"Critical Care Medicine","DOI":"10.1097/00003246-200008000-00064","ISSN":"0090-3493","issue":"8","journalAbbreviation":"Crit. Care Med.","language":"eng","note":"PMID: 10966296","page":"3060-3066","source":"PubMed","title":"End-of-life care in the pediatric intensive care unit after the forgoing of life-sustaining treatment","volume":"28","author":[{"family":"Burns","given":"J. P."},{"family":"Mitchell","given":"C."},{"family":"Outwater","given":"K. M."},{"family":"Geller","given":"M."},{"family":"Griffith","given":"J. L."},{"family":"Todres","given":"I. D."},{"family":"Truog","given":"R. D."}],"issued":{"date-parts":[["2000",8]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Burns et al., 2000). Studies suggest that the factors that influence the physician's decision to withdraw mechanical ventilation include the severity of patient's disease, chronic problems associated with the disease, patient's age, patient's desires, and the future quality of life. Moreover, it is also established that physicians might withdraw the interventions that are aggressive and costly if the condition of the patient does not seem to improve. Interventions that are associated with physician specialization, often become the reason for the physician’s decision of withdrawing the mechanical ventilation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"p6oWAzTp","properties":{"formattedCitation":"(Medford, 2003)","plainCitation":"(Medford, 2003)","noteIndex":0},"citationItems":[{"id":470,"uris":["http://zotero.org/users/local/CKNkWnK9/items/G92U9XYN"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/G92U9XYN"],"itemData":{"id":470,"type":"article-journal","abstract":"▴ Cook D, Rocker G, Marshall J, et al . Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med2003;349:1123–32\n\n[OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4]\n\n\n\nEight hundred and fifty one consecutive patients mechanically ventilated for at least 72 hours in intensive care units in 15 different centres were prospectively followed. The relation between various factors and withdrawal of mechanical ventilation was assessed using …\n\n [1]: {openurl}?query=rft.jtitle%253DNew%2BEngland%2BJournal%2Bof%2BMedicine%26rft.stitle%253DNEJM%26rft.issn%253D0028-4793%26rft.aulast%253DCook%26rft.auinit1%253DD.%26rft.volume%253D349%26rft.issue%253D12%26rft.spage%253D1123%26rft.epage%253D1132%26rft.atitle%253DWithdrawal%2Bof%2BMechanical%2BVentilation%2Bin%2BAnticipation%2Bof%2BDeath%2Bin%2Bthe%2BIntensive%2BCare%2BUnit%26rft_id%253Dinfo%253Adoi%252F10.1056%252FNEJMoa030083%26rft_id%253Dinfo%253Apmid%252F13679526%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\n [2]: /lookup/external-ref?access_num=10.1056/NEJMoa030083&link_type=DOI\n [3]: /lookup/external-ref?access_num=13679526&link_type=MED&atom=%2Fthoraxjnl%2F58%2F12%2F1041.atom\n [4]: /lookup/external-ref?access_num=000185369700005&link_type=ISI","container-title":"Thorax","DOI":"10.1136/thorax.58.12.1041","ISSN":"0040-6376, 1468-3296","issue":"12","language":"en","page":"1041-1041","source":"thorax.bmj.com","title":"Factors associated with physicians’ decisions to withdraw mechanical ventilation in anticipation of death","volume":"58","author":[{"family":"Medford","given":"A. R. L."}],"issued":{"date-parts":[["2003",12,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Medford, 2003).
Studies state that it is understood that withdrawal practice affects the patient in many ways, however, family suffers from another kind of pain ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aVy9fyk1","properties":{"formattedCitation":"(Newborn, 2007)","plainCitation":"(Newborn, 2007)","noteIndex":0},"citationItems":[{"id":464,"uris":["http://zotero.org/users/local/CKNkWnK9/items/W4TTBQZW"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/W4TTBQZW"],"itemData":{"id":464,"type":"article-journal","abstract":"Advances in medical technology have led to dilemmas in initiation and withdrawal of intensive care of newborn infants with a very poor prognosis. Physicians and parents together must make difficult decisions guided by their understanding of the child's best interest. The foundation for these decisions consists of several key elements: (1) direct and open communication between the health care team and the parents of the child with regard to the medical status, prognosis, and treatment options; (2) inclusion of the parents as active participants in the decision process; (3) continuation of comfort care even when intensive care is not being provided; and (4) treatment decisions that are guided primarily by the best interest of the child.","container-title":"Pediatrics","DOI":"10.1542/peds.2006-3180","ISSN":"0031-4005, 1098-4275","issue":"2","language":"en","note":"PMID: 17272630","page":"401-403","source":"pediatrics.aappublications.org","title":"Noninitiation or Withdrawal of Intensive Care for High-Risk Newborns","volume":"119","author":[{"family":"Newborn","given":"Committee on Fetus","dropping-particle":"and"}],"issued":{"date-parts":[["2007",2,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Newborn, 2007). However, if we talk about the withdrawal of mechanical ventilation in neonatal or pediatric patients, the practice seems to effect parents more than the patient. Many physicians believe that it is important to support the family in this critical time so they do not think they are being abandoned ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"BNogobp2","properties":{"formattedCitation":"(Munson, 2007)","plainCitation":"(Munson, 2007)","noteIndex":0},"citationItems":[{"id":461,"uris":["http://zotero.org/users/local/CKNkWnK9/items/2SBWBF4W"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/2SBWBF4W"],"itemData":{"id":461,"type":"article-journal","container-title":"Pediatric Clinics of North America","DOI":"10.1016/j.pcl.2007.08.001","ISSN":"00313955","issue":"5","journalAbbreviation":"Pediatric Clinics of North America","language":"en","page":"773-785","source":"DOI.org (Crossref)","title":"Withdrawal of Mechanical Ventilation in Pediatric and Neonatal Intensive Care Units","volume":"54","author":[{"family":"Munson","given":"David"}],"issued":{"date-parts":[["2007",10]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Munson, 2007). Although some families want privacy, it is the responsibility of clinicians to ensure that families are provided with their required needs. It is important that physicians daily inform the family and relatives about the patient’s health and condition daily. However, in some case, it is reported that the family may decide to discontinue the mechanical ventilation due to the increasing financial burden. This mainly happens in the cases, when the patient is receives artificial life support for a very long time and shows no positive signs of improvement. Studies evidently suggest that the decision of this practice is influenced either by physicians, family or the patient himself ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"GxaoOmgO","properties":{"formattedCitation":"(Medford, 2003)","plainCitation":"(Medford, 2003)","noteIndex":0},"citationItems":[{"id":470,"uris":["http://zotero.org/users/local/CKNkWnK9/items/G92U9XYN"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/G92U9XYN"],"itemData":{"id":470,"type":"article-journal","abstract":"▴ Cook D, Rocker G, Marshall J, et al . Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med2003;349:1123–32\n\n[OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4]\n\n\n\nEight hundred and fifty one consecutive patients mechanically ventilated for at least 72 hours in intensive care units in 15 different centres were prospectively followed. The relation between various factors and withdrawal of mechanical ventilation was assessed using …\n\n [1]: {openurl}?query=rft.jtitle%253DNew%2BEngland%2BJournal%2Bof%2BMedicine%26rft.stitle%253DNEJM%26rft.issn%253D0028-4793%26rft.aulast%253DCook%26rft.auinit1%253DD.%26rft.volume%253D349%26rft.issue%253D12%26rft.spage%253D1123%26rft.epage%253D1132%26rft.atitle%253DWithdrawal%2Bof%2BMechanical%2BVentilation%2Bin%2BAnticipation%2Bof%2BDeath%2Bin%2Bthe%2BIntensive%2BCare%2BUnit%26rft_id%253Dinfo%253Adoi%252F10.1056%252FNEJMoa030083%26rft_id%253Dinfo%253Apmid%252F13679526%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx\n [2]: /lookup/external-ref?access_num=10.1056/NEJMoa030083&link_type=DOI\n [3]: /lookup/external-ref?access_num=13679526&link_type=MED&atom=%2Fthoraxjnl%2F58%2F12%2F1041.atom\n [4]: /lookup/external-ref?access_num=000185369700005&link_type=ISI","container-title":"Thorax","DOI":"10.1136/thorax.58.12.1041","ISSN":"0040-6376, 1468-3296","issue":"12","language":"en","page":"1041-1041","source":"thorax.bmj.com","title":"Factors associated with physicians’ decisions to withdraw mechanical ventilation in anticipation of death","volume":"58","author":[{"family":"Medford","given":"A. R. L."}],"issued":{"date-parts":[["2003",12,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Medford, 2003).
In the neonatal care unit, discontinuing the ventilator intervention poses serious ethical challenges ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cQ0lSImf","properties":{"formattedCitation":"(Rubenfeld, 2004)","plainCitation":"(Rubenfeld, 2004)","noteIndex":0},"citationItems":[{"id":462,"uris":["http://zotero.org/users/local/CKNkWnK9/items/DRSSCZVD"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/DRSSCZVD"],"itemData":{"id":462,"type":"article-journal","abstract":"The clinician's responsibility to the patient does not end with a decision to limit medical treatment, but continues through the dying process. Every effort should be made to ensure that withdrawing life support occurs with the same quality and attention to detail as is routinely provided when life support is initiated. Approaching the withdrawal of life support as a medical procedure provides clinicians with a recognizable framework for their actions. Key steps in this process are identifying and communicating explicit shared goals for the process, approaching withdrawal of life-sustaining treatments asa medical procedure, and preparing protocols and materials to assure consistent care. Our hope is that adopting a more formal approach to this common procedure will improve the care of patients dying in intensive care units.","container-title":"Critical Care Clinics","DOI":"10.1016/j.ccc.2004.03.005","ISSN":"0749-0704","issue":"3","journalAbbreviation":"Crit Care Clin","language":"eng","note":"PMID: 15183212","page":"435-451, ix","source":"PubMed","title":"Principles and practice of withdrawing life-sustaining treatments","volume":"20","author":[{"family":"Rubenfeld","given":"Gordon D."}],"issued":{"date-parts":[["2004",7]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Rubenfeld, 2004). The major ethical concern is the patient’s hunger for air leading to severe breathing discomfort. Even after the withdrawal of mechanical ventilation, doctors and nurses are responsible to provide comfort to the patients by trying to manage the symptoms of distress the patients experience during their death. One approach to relieve this discomfort is the use of narcotics ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"TXDvcZZY","properties":{"formattedCitation":"(Rubenfeld, 2004)","plainCitation":"(Rubenfeld, 2004)","noteIndex":0},"citationItems":[{"id":462,"uris":["http://zotero.org/users/local/CKNkWnK9/items/DRSSCZVD"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/DRSSCZVD"],"itemData":{"id":462,"type":"article-journal","abstract":"The clinician's responsibility to the patient does not end with a decision to limit medical treatment, but continues through the dying process. Every effort should be made to ensure that withdrawing life support occurs with the same quality and attention to detail as is routinely provided when life support is initiated. Approaching the withdrawal of life support as a medical procedure provides clinicians with a recognizable framework for their actions. Key steps in this process are identifying and communicating explicit shared goals for the process, approaching withdrawal of life-sustaining treatments asa medical procedure, and preparing protocols and materials to assure consistent care. Our hope is that adopting a more formal approach to this common procedure will improve the care of patients dying in intensive care units.","container-title":"Critical Care Clinics","DOI":"10.1016/j.ccc.2004.03.005","ISSN":"0749-0704","issue":"3","journalAbbreviation":"Crit Care Clin","language":"eng","note":"PMID: 15183212","page":"435-451, ix","source":"PubMed","title":"Principles and practice of withdrawing life-sustaining treatments","volume":"20","author":[{"family":"Rubenfeld","given":"Gordon D."}],"issued":{"date-parts":[["2004",7]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Rubenfeld, 2004). Studies indicate that there is a dilemma among the physicians regarding the use of narcotics to soothe the symptoms of discomfort after the withdrawal of intervention ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"pkHYeQtb","properties":{"formattedCitation":"(Munson, 2007)","plainCitation":"(Munson, 2007)","noteIndex":0},"citationItems":[{"id":461,"uris":["http://zotero.org/users/local/CKNkWnK9/items/2SBWBF4W"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/2SBWBF4W"],"itemData":{"id":461,"type":"article-journal","container-title":"Pediatric Clinics of North America","DOI":"10.1016/j.pcl.2007.08.001","ISSN":"00313955","issue":"5","journalAbbreviation":"Pediatric Clinics of North America","language":"en","page":"773-785","source":"DOI.org (Crossref)","title":"Withdrawal of Mechanical Ventilation in Pediatric and Neonatal Intensive Care Units","volume":"54","author":[{"family":"Munson","given":"David"}],"issued":{"date-parts":[["2007",10]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Munson, 2007). Some physicians believe that it immediately brings death to their patients and they blame themselves for it while other states that it does not shorten time to death but instead it aggravates it. This is mainly a two concept approach where the former is known as a “double effect”. It is established that lower doses of narcotics such as fentanyl, morphine and hydromorphone, may contribute to the purpose of relieving the symptoms experienced at the end of the death. However, if large doses of these substances are used, it aggravates the time to death with further increasing the respiratory distress and hunger for air because of its side effects. It is more often observed in adult patients who are given large doses of benzodiazepines ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"iUT4NuPb","properties":{"formattedCitation":"(Burns et al., 2000)","plainCitation":"(Burns et al., 2000)","noteIndex":0},"citationItems":[{"id":468,"uris":["http://zotero.org/users/local/CKNkWnK9/items/32NQU9MV"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/32NQU9MV"],"itemData":{"id":468,"type":"article-journal","abstract":"OBJECTIVE: To describe the attitudes and practice of clinicians in providing sedation and analgesia to dying patients as life-sustaining treatment is withdrawn.\nSTUDY DESIGN: Prospective case series of 53 consecutive patients who died after the withdrawal of life-sustaining treatment in the pediatric intensive care unit at three teaching hospitals in Boston. Data on the reasons why medications were given were obtained from a self-administered anonymous questionnaire completed by the critical care physician and nurse for each case. Data on what medications were given were obtained from a review of the medical record.\nRESULTS: Sedatives and/or analgesics were administered to 47 (89%) patients who died after the withdrawal of life-sustaining treatment. Patients who were comatose were less likely to receive these medications. Physicians and nurses cited treatment of pain, anxiety, and air hunger as the most common reasons, and hastening death as the least common reason, for administration of these medications. Hastening death was viewed as an \"acceptable, unintended side effect\" of terminal care by 91% of physician-nurse matched pairs. The mean dose of sedatives and analgesics administered nearly doubled as life-support was withdrawn, and the degree of escalation in dose did not correlate with clinician's views on hastening death.\nCONCLUSION: Clinicians frequently escalate the dose of sedatives or analgesics to dying patients as life-sustaining treatment is withdrawn, citing patient-centered reasons as their principle justification. Hastening death is seen as an unintended consequence of appropriate care. A large majority of physicians and nurses agreed with patient management and were satisfied with the care provided. Care of the dying patient after the forgoing of life-sustaining treatment remains underanalyzed and needs more rigorous examination by the critical care community.","container-title":"Critical Care Medicine","DOI":"10.1097/00003246-200008000-00064","ISSN":"0090-3493","issue":"8","journalAbbreviation":"Crit. Care Med.","language":"eng","note":"PMID: 10966296","page":"3060-3066","source":"PubMed","title":"End-of-life care in the pediatric intensive care unit after the forgoing of life-sustaining treatment","volume":"28","author":[{"family":"Burns","given":"J. P."},{"family":"Mitchell","given":"C."},{"family":"Outwater","given":"K. M."},{"family":"Geller","given":"M."},{"family":"Griffith","given":"J. L."},{"family":"Todres","given":"I. D."},{"family":"Truog","given":"R. D."}],"issued":{"date-parts":[["2000",8]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Burns et al., 2000).
In Pediatrics research, the mechanism to discontinue mechanical ventilation is hardly presented. However, one research states that there are two main approaches to withdraw ventilator off a patient: Terminal Weaning and Terminal Extubation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Up1fkSBN","properties":{"formattedCitation":"(Munson, 2007)","plainCitation":"(Munson, 2007)","noteIndex":0},"citationItems":[{"id":461,"uris":["http://zotero.org/users/local/CKNkWnK9/items/2SBWBF4W"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/2SBWBF4W"],"itemData":{"id":461,"type":"article-journal","container-title":"Pediatric Clinics of North America","DOI":"10.1016/j.pcl.2007.08.001","ISSN":"00313955","issue":"5","journalAbbreviation":"Pediatric Clinics of North America","language":"en","page":"773-785","source":"DOI.org (Crossref)","title":"Withdrawal of Mechanical Ventilation in Pediatric and Neonatal Intensive Care Units","volume":"54","author":[{"family":"Munson","given":"David"}],"issued":{"date-parts":[["2007",10]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Munson, 2007). Gradually reducing the ventilator support before extubation is called as a “terminal weaning” while “terminal extubation” is characterized as the removal of endotracheal pipe without dissuading ventilator sustenance. Physicians predict both approaches are rather unclear considering the merits and demerits. However, terminal weaning is prioritized over terminal extubation because physicians believe they get enough time to prepare sedation medication to ease the symptoms patient experience at the end of the death ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"IJbh72yf","properties":{"formattedCitation":"(Rubenfeld, 2004)","plainCitation":"(Rubenfeld, 2004)","noteIndex":0},"citationItems":[{"id":462,"uris":["http://zotero.org/users/local/CKNkWnK9/items/DRSSCZVD"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/DRSSCZVD"],"itemData":{"id":462,"type":"article-journal","abstract":"The clinician's responsibility to the patient does not end with a decision to limit medical treatment, but continues through the dying process. Every effort should be made to ensure that withdrawing life support occurs with the same quality and attention to detail as is routinely provided when life support is initiated. Approaching the withdrawal of life support as a medical procedure provides clinicians with a recognizable framework for their actions. Key steps in this process are identifying and communicating explicit shared goals for the process, approaching withdrawal of life-sustaining treatments asa medical procedure, and preparing protocols and materials to assure consistent care. Our hope is that adopting a more formal approach to this common procedure will improve the care of patients dying in intensive care units.","container-title":"Critical Care Clinics","DOI":"10.1016/j.ccc.2004.03.005","ISSN":"0749-0704","issue":"3","journalAbbreviation":"Crit Care Clin","language":"eng","note":"PMID: 15183212","page":"435-451, ix","source":"PubMed","title":"Principles and practice of withdrawing life-sustaining treatments","volume":"20","author":[{"family":"Rubenfeld","given":"Gordon D."}],"issued":{"date-parts":[["2004",7]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Rubenfeld, 2004). Another reason why physicians think it is better than the terminal extubation is that it provides the necessary time for the family to deal with the death and often say goodbye to their patient ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"e6eg4S8g","properties":{"formattedCitation":"(Rubenfeld, 2004)","plainCitation":"(Rubenfeld, 2004)","noteIndex":0},"citationItems":[{"id":462,"uris":["http://zotero.org/users/local/CKNkWnK9/items/DRSSCZVD"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/DRSSCZVD"],"itemData":{"id":462,"type":"article-journal","abstract":"The clinician's responsibility to the patient does not end with a decision to limit medical treatment, but continues through the dying process. Every effort should be made to ensure that withdrawing life support occurs with the same quality and attention to detail as is routinely provided when life support is initiated. Approaching the withdrawal of life support as a medical procedure provides clinicians with a recognizable framework for their actions. Key steps in this process are identifying and communicating explicit shared goals for the process, approaching withdrawal of life-sustaining treatments asa medical procedure, and preparing protocols and materials to assure consistent care. Our hope is that adopting a more formal approach to this common procedure will improve the care of patients dying in intensive care units.","container-title":"Critical Care Clinics","DOI":"10.1016/j.ccc.2004.03.005","ISSN":"0749-0704","issue":"3","journalAbbreviation":"Crit Care Clin","language":"eng","note":"PMID: 15183212","page":"435-451, ix","source":"PubMed","title":"Principles and practice of withdrawing life-sustaining treatments","volume":"20","author":[{"family":"Rubenfeld","given":"Gordon D."}],"issued":{"date-parts":[["2004",7]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Rubenfeld, 2004). In the neonatal Intensive Care Unit, this approach may allow parents to hold their baby in the time the physician prepares a sedation medicine. Moreover, with a progressive decline of oxygen and elevation in carbon dioxide, the patient is more likely to experience sedation. However, the side effect of this approach is that it prolongs the dying process which ultimately increases the time of the patient's suffering ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1UFeiXe2","properties":{"formattedCitation":"(Munson, 2007)","plainCitation":"(Munson, 2007)","noteIndex":0},"citationItems":[{"id":461,"uris":["http://zotero.org/users/local/CKNkWnK9/items/2SBWBF4W"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/2SBWBF4W"],"itemData":{"id":461,"type":"article-journal","container-title":"Pediatric Clinics of North America","DOI":"10.1016/j.pcl.2007.08.001","ISSN":"00313955","issue":"5","journalAbbreviation":"Pediatric Clinics of North America","language":"en","page":"773-785","source":"DOI.org (Crossref)","title":"Withdrawal of Mechanical Ventilation in Pediatric and Neonatal Intensive Care Units","volume":"54","author":[{"family":"Munson","given":"David"}],"issued":{"date-parts":[["2007",10]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Munson, 2007). It is reported that the approach also affects the family due to the prolonged time of death which increases the anxiety among the family in a case where the family has already accepted the fate of their patient. Some physicians give solution to this problem by suggesting a shift of terminal weaning to terminal extubation right after the medication has been titrated. It will accomplish the main purpose of sparing the patient with the suffering of prolonged death ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"vF1u4ghA","properties":{"formattedCitation":"(Rubenfeld, 2004)","plainCitation":"(Rubenfeld, 2004)","noteIndex":0},"citationItems":[{"id":462,"uris":["http://zotero.org/users/local/CKNkWnK9/items/DRSSCZVD"],"uri":["http://zotero.org/users/local/CKNkWnK9/items/DRSSCZVD"],"itemData":{"id":462,"type":"article-journal","abstract":"The clinician's responsibility to the patient does not end with a decision to limit medical treatment, but continues through the dying process. Every effort should be made to ensure that withdrawing life support occurs with the same quality and attention to detail as is routinely provided when life support is initiated. Approaching the withdrawal of life support as a medical procedure provides clinicians with a recognizable framework for their actions. Key steps in this process are identifying and communicating explicit shared goals for the process, approaching withdrawal of life-sustaining treatments asa medical procedure, and preparing protocols and materials to assure consistent care. Our hope is that adopting a more formal approach to this common procedure will improve the care of patients dying in intensive care units.","container-title":"Critical Care Clinics","DOI":"10.1016/j.ccc.2004.03.005","ISSN":"0749-0704","issue":"3","journalAbbreviation":"Crit Care Clin","language":"eng","note":"PMID: 15183212","page":"435-451, ix","source":"PubMed","title":"Principles and practice of withdrawing life-sustaining treatments","volume":"20","author":[{"family":"Rubenfeld","given":"Gordon D."}],"issued":{"date-parts":[["2004",7]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Rubenfeld, 2004).
Withdrawing advanced life support interventions in a medical setting depends upon the wide range of concepts and resources in order to effectively provide the required care. By adopting certain practices of effective communication and management at the time of withdrawal, paediatricians can improve the care provided to the patient and their families at the time of death.
References
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Munson, D. (2007). Withdrawal of Mechanical Ventilation in Pediatric and Neonatal Intensive Care Units. Pediatric Clinics of North America, 54(5), 773–785. https://doi.org/10.1016/j.pcl.2007.08.001
Newborn, C. on F. and. (2007). Noninitiation or Withdrawal of Intensive Care for High-Risk Newborns. Pediatrics, 119(2), 401–403. https://doi.org/10.1542/peds.2006-3180
Rubenfeld, G. D. (2004). Principles and practice of withdrawing life-sustaining treatments. Critical Care Clinics, 20(3), 435–451, ix. https://doi.org/10.1016/j.ccc.2004.03.005