撤除維生醫療查核及程序 Withdrawal of mechanical ventilation protocol

撤除維生醫療查核及程序 Withdrawal of mechanical ventilation protocol

Medical Provider Preparations - Provider is to assure that: 1.確定已取得下列意願書或同意書正本之其中之一種：     □末期病人或醫療委任代理人已簽署意願書選擇安寧緩和醫療或撤除維生醫療。且已記錄於電子病歷中。     □末期病人之最近親屬中之一人已簽署撤除維生醫療同意書。且已記錄於電子病歷中。 2.主治醫師已於病歷上記錄下列事項：      □ 末期病人符合不施行心肺復甦術的條件。      □ 已會同另一位相關專科醫師診斷確為末期病人。 □3.已完成倫理諮詢會診。 □4.由主治醫療團隊召開緩和醫療家庭會議並開立緩和醫療家庭諮詢費(Palliative Care family Conference Fee)之治療醫囑。 5.已於適當情境下(如家庭會議)告知家屬以下事項：     □ 撤除維生醫療之目標並非立即導致死亡，撤除後病人仍可能存活一段時間後依自然病程進入死亡。     □ 會盡量考量病人或家屬之需求，照護之目標在於舒適與尊嚴。     □ 若病人狀況允許考慮撤除後行器官捐贈。 □6.已照會安寧緩和醫療團隊。 □7.主治醫師已開立撤除維生醫療(Withdrawal of Life-Sustaining Treatment)之醫囑。同時與護理師、和呼吸治療師（RT）討論醫囑。 □8.停止重症照護常規：如抽血檢驗、影像學檢查、抗生素、血液透析、輸血等。 □9.移除不必要之監測，僅留 EKG monitor 及/或 oximeter. □10.確認撤除維生醫療措施的項目並對家屬解釋說明之。 □11.家屬可自由探視的時間。 預定撤除維生醫療措施之時間:西元____年__月__ 日 __時

2. Nursing Preparations (護理準備):  □ 停止所有醫囑, including routine vital signs, blood glucose, lab orders, x-rays, medications, enteral feedings, IV fluids, and infusions of Propofol and paralytic agents. (If patient has been on paralytic agent, return of motor function must be demonstrated).  □ Discontinue monitors in patient's room and remove nasogastric tubes, blood pressure and leg compression cuffs.  □ Notify on-call team of impending withdrawal.

3. Nursing Care: (護理照護) •          如果家屬希望，可讓家屬參與呼吸器的移除。 •         將頭部與床維持 30 - 45度。 •         預防死前喉鳴:可施予 Buscopan 20 mg IV stat •         預防拔管後哮鳴:可施予 Solucortef 100 mg IV stat •          照會安寧團隊與支持家庭喪親之痛。如果病人在拔管後1小時，病情 穩定，可轉入單人病房由原本醫療團隊與安寧團隊接手照顧。

4. Ventilator (check one): □ Extubate to nasal cannula 2 L/minute. May administer below PRN morphine, fentanyl and/or lorazepam 10 minutes prior to extubation. □ Terminal wean • Change ventilator mode to SIMV with rate 12/min and pressure support (PS) 5 cm, FiO2 0.5 and PEEP 5 cm. • Reduce FiO2 to 0.30 and PEEP to zero over less than 5 minutes and titrate comfort medications. • When patient is comfortable, wean rate to 4/min and again titrate comfort medications. • When comfort achieved, either (check one):  □ extubate to nasal cannula 2L/min. or ______________________________.   □ place on T piece with FiO2 0.3

5. Medications:  • To treat discomfort related to pain and/or dyspnea (check one):  □    Morphine 5 mg IV every 10 minutes PRN discomfort. Or Morphine ______ (range 1-10) mg IV every 10 minutes PRN discomfort  □    Fentanyl 50 micrograms IV every 10 minutes PRN discomfort. Or Fentanyl _______ (range 25-100) micrograms IV every 10 minutes PRN discomfort □    Morphine drip at current rate or at ________ mg/hr. May give additional IV morphine bolus up to 50% the current hourly rate every 10 minutes. May increase infusion rate by 25% every 10 minutes for signs of discomfort not relieved by bolus. □    Fentanyl drip at current rate or at _______mcg/hr. May give additional IV fentanyl bolus up to 50% the current hourly rate every 10 minutes. May increase infusion rate by 25% every 10 minutes for signs of discomfort not relieved by bolus. □    Other opiate:__________________________________________________ □    None, Notify physician if patient shows signs of discomfort • To treat discomfort related to agitation or anxiety (check one): □ Lorazepam 1-2 mg IV every 10 minutes PRN discomfort  □ Lorazepam drip at current rate or at ________ (range 1-10) mg/hr. May give additional IV lorazepam bolus up to 50% the current hourly rate every 10 minutes. May increase infusion rate by 25% every 15 minutes for signs of discomfort not relieved by bolus. □ Midazolam 1-2 mg IV every 10 minutes PRN discomfort  Midazolam drip at current rate or at ________ (range 1-10) mg/hr. May give additional IV Midazolam bolus up to 50% the current hourly rate every 10 minutes. May increase infusion rate by 25% every 15 minutes for signs of discomfort not relieved by bolus.  □ Other benzodiazepine: _________________________________  □ None; notify physician if patient shows signs of discomfort. • To prevent high oral secretion. A.k.a. “dead rattle”. (check below)  □ Glycopyrrolate 0.2 mg IV at least 30 minutes prior to extubation. □ Follow by Glycopyrrolate 0.2mg IV every _____ hours as needed (range 4-8hr) for high oral secretion. □ For significant thin oral secretions, scopolamine 1.5mg patch • For temp greater than 38.2° C, give Voltaren 25-50mg per rectum every 8 hours PRN.

6. Discontinue vasopressors, inotropes and antiarrhythmics simultaneous with either extubation or placement on T piece

7. Inform attending team of patient’s death to pronounce whenever that occurs.

和信治癌中心醫院臨床藥師方麗華整理撰寫

Reference

1. Stacy KM. Withdrawal of Life-Sustaining Treatment A Case Study. Critical care nurse, 2012;32[3]:14-24.

2. Reference to ventilator withdrawal policies. Massachusetts General Hospital Policy and Procedures: Limitation of Life Sustaining Treatment Policy. Harborview Medical Center-University of Washington Medical Center, Seattle, Washington, “Comfort Care Orders for the Withdrawal of Life Support in the ICU.” The Johns Hopkins Hospital, Policy: “Procedure for Withdrawal of Life Support in the MICU/MCP.” Hospice and Palliative Care of Metropolitan Washington Protocol: “Discontinuing of Ventilator Support.” 2001.

3. Physician’s order set / Protocol withdrawal of life sustaining measures – New Hanover Regional Medical center. NS-1787. 0064 (2007. V5.)

4. Riker R, Picard J, Fraser G. Prospective evaluation of the sedation-agitation scale in adult ICU patients. Crit. Care Med 1999; 27:1325-1329.

5. Simmons L, Riker R, Prato B, Fraser G. Assessing sedation in ventilated ICU patients with the bispectral index and the sedation-agitation scale. Crit. Care Med 1999; 27:1499-1504.

6. Brandl K, Langley K, Riker R, Dork L, Quails C, Levy H. Confirming the reliability of the Sedation-AgitationScale in ICU nurses without prior experience in its use. Pharmacotherapy 2001; 21:431-436.

7. Richard R, Gilles L, Lavone E , Micheline L. Validating the Sedation-Agitation Scale with the bispectral index and visual analog scale in adult ICU patients after cardiac surgery. Intensive Care Med 2001; 27:853- 858.

8. Massachusetts General Hospital, Medical ICU Project (2006, July): Ventilator Withdrawal Guidelines. http://www.aacn.org/WD/Palliative/Docs/mgh8.pdf