Vol. 59 No.

1 January 2020 Journal of Pain and Symptom Management 165

Educational Exchange
Series Editor: Amy A. Case, MD, FAAHPM

Ventilator Withdrawal in Anticipation of Death:

The Simulation Lab as an Educational
Tool in Palliative Medicine
Mei-Ean Yeow, BMBCh, FACP, FAAHPM, and Elaine Chen, MD, FCCP
Center for Palliative Medicine (M.-E.Y.), Mayo Clinic, Rochester, Minnesota; and Division of Pulmonary & Critical Care Medicine and
Section of Palliative Medicine (E.C.), Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA

Abstract
Simulation is a growing model of education in many medical disciplines. Withdrawal of mechanical ventilation is an important skill set for
palliative medicine practitioners who must be facile with a variety of end-of-life scenarios and is well suited to the simulation laboratory. We
describe a novel approach using high-fidelity simulation to design a curriculum to teach Hospice & Palliative Medicine fellows the practical
aspects of managing a compassionate terminal extubation. This simulation session aims to equip palliative fellows with a knowledge base of
respiratory physiology and mechanical ventilation as well as the practical experience of performing a terminal extubation. We designed a three-
hour simulation session which includes a one-hour didactic followed by two hours of simulation, with four cases that focus on different
teaching points regarding symptom management and practical aspects of removing the endotracheal tube. The session was designed as an
annual session for Hospice & Palliative Medicine fellows in our region during a collaborative educational conference. Based on feedback, the
session is scheduled for the beginning of the academic year and each fellow is given the opportunity to physically remove the endotracheal tube.
Simulation can be effectively used to teach practical and complex bedside skills such as withdrawal of mechanical ventilation to palliative
medicine trainees. This method of teaching could be expanded to teach other advanced hospice and palliative care skills. J Pain Symptom
Manage 2020;59:165e171. Ó 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Key Words
Compassionate extubation, simulation, mechanical ventilation

Introduction management, often with infusions. An understand-

Ventilator withdrawal in anticipation of death,
sometimes called compassionate or terminal extuba-
tion, is an important aspect of end-of-life care in the
hospital. In a national survey, approximately 40% of
all intensive care unit (ICU) deaths involved with-
drawal of life support.1,2
A compassionate extubation is a complex process
that involves high-level counseling and communica-
tion with family (and possibly with the patient
themselves), expertise with mechanical ventilation,
other oxygen delivery devices, monitors and other
equipment, and complex and intensive symptom
ing of simultaneous other medical issues is
important, and prognostication can be very
challenging.3e5
Although most compassionate extubations occur in
ICU and are overseen by the ICU team, there are
increasing occasions where palliative providers are
called upon to facilitate this process. In some medical
centers, the presence of an onsite in-patient hospice
unit allows for increasing occurrences of compas-
sionate extubations in the hospice setting. The hos-
pice team is then responsible for facilitating the
extubation process. In addition, patients or families
may request that compassionate extubation occurs in

Address correspondence to: Mei-Ean Yeow, BMBCh, FACP, Accepted for publication: September 30, 2019.
FAAHPM, Center for Palliative Medicine, Mayo Clinic, 200
1st St SW, Rochester, MN 55905, USA. E-mail:
Yeow.Mei-Ean@mayo.edu

Ó 2019 American Academy of Hospice and Palliative Medicine. 0885-3924/$ - see front matter
Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jpainsymman.2019.09.025

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166
the home setting, under the auspices of the home hos-
pice team.6,7 Thus, Palliative Medicine providers
should be comfortable both counseling about and
facilitating these extubations, in whatever setting
they occur. It is therefore imperative that our Hospice
& Palliative Medicine (HPM) fellows are equipped
with the knowledge and expertise to lead and manage
the extubation event itself.
In 2006, the American Board of Medical Specialties
approved the creation of HPM as a subspecialty of 10
participating boards. These remain the same 10 spe-
cialties eligible for training in 2019. There is evidence
of increasing diversity in the field, with greater repre-
sentation from fields other than Internal Medicine.
Some trainees have extensive ICU experience,
whereas others may not have had significant experi-
ence in the critical care setting or with patients
receiving mechanical ventilation. We therefore set
out to develop a curriculum that provided a knowl-
edge base of respiratory physiology and mechanical
ventilation as well as the practical aspects of
extubation.
Simulation labs have been shown to enhance the
learning experience and improve procedural skills
by providing a safe environment to practice and
make mistakes without jeopardizing patient care.
High-fidelity simulation refers to simulation that in-
corporates a computerized full-body manikin that
can be programmed to provide realistic physiologic
response to practitioner actions. These simulations
require a realistic environment and the use of
actual medical equipment and supplies.8 High-
fidelity simulation has been used to train residents
in resuscitation and refining procedural skills.9 In
palliative medicine education, simulation has pri-
marily been focused on actor-based role-play to
improve communication skills. To our knowledge,
high-fidelity simulation using computerized mani-
kins has not been described as a teaching modality
for compassionate extubation for palliative care
providers.
Innovation
We describe a novel approach using high-fidelity
simulation as an educational tool to teach HPM fel-
lows the background as well as technical and practical
aspects of managing a compassionate extubation. We
designed a three-hour curriculum that included a
one-hour didactic followed by two hours of simulation
laboratory experience. The designing faculty included
two physicians with experience and board certification
in both critical care and hospice and palliative
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Yeow and Chen Vol. 59 No. 1 January 2020
medicine. This session was designed in close collabo-
ration with simulation lab faculty and staff.
Session Design
The didactic was prepared by the authors and de-
tails aspects of ventilator withdrawal and ICU care
that are pertinent to HPM fellows. The simulation
scenarios focus on different teaching points garnered
from real-life experience in the ICU. This session is
held during the first month of fellowship, as this
was felt to be an important skill for the HPM fellows
to learn at the beginning of the academic year and
subsequently practice over the course of their
training.
Session Participants
This session was designed as part of a Regional Fel-
lows’ Conference. This conference is an educational
collaboration among the HPM fellowships in our re-
gion, which have been growing. This simulation expe-
rience is geared toward small group learning of
between eight and 16 learners, with an optimal group
size of 10e12. Each case should have two to four
learners playing different roles on the bedside clinical
team.
Session Staff
The didactic portion of the session is delivered
by a single palliative medicine faculty member.
The simulation portion of the session requires
more faculty and staff participation. We have a
minimum of three simulation lab staff and two
palliative faculty present for the session. One mem-
ber of the simulation lab team staffs the control
room, and one to two members of the simulation
lab team (or actors/standardized patients) act as
the nurse (RN), respiratory therapist (RT), family
member, and/or the awake intubated patient. De-
pending on staffing levels, one staff member may
play dual roles in a single simulation case (such
as ancillary staff and family members). Palliative
Medicine Faculty are present to guide and debrief
each case. If dual trained Critical Care and Pallia-
tive Care faculty were not available, an effort was
made to have a faculty member from Pulmonary/
Critical Care present as well.
Session Format
The one-hour didactic takes place in a conference
room equipped with standard computer and projector
equipment. The two-hour simulation session takes
place in the simulation lab and comprises four cases
of 30 minutes each. The simulation staff prepares
the room, using equipment as detailed in Table 1.
Vol. 59 No. 1 January 2020
Table 1
Equipment Needed in Simulation Lab
Manikin
Monitors
Ventilator
Endotracheal tube/ties
10 mL syringe
Suction apparatus
Towel
Nasal cannula
Drips at bedside
Each case would begin with a three- to five-minute pre-
huddle for the participants to read the case and pre-
pare, followed by a 15-minute simulation session,
with the remaining learners viewing from either a con-
ference room via video-link, or from within the simu-
lation room. After each case, a debriefing session is
facilitated by the Palliative Medicine Faculty with
both the active participants as well as the observers.
At the conclusion of the session, all participants are
asked to fill out a feedback form.
Didactic
The session starts with an hour-long didactic. The
didactic begins as a refresher course on respiratory
physiology, interpretation of arterial blood gases, and
the basics of mechanical ventilation. This is followed
by a case-based discussion of topics to help guide the
trainees through the simulation cases. The topics are
summarized in the following sections.
Principles of a Spontaneous Breathing Trial
The principles of a Spontaneous Breathing Trial
(SBT) are reviewed. SBTs were originally designed to
assess if intubated patients were ready to be liberated
from the ventilator, through monitoring of multiple
respiratory and hemodynamic parameters over a set
time period. Components of the SBT can also be
used to gauge the expected burden of symptoms after
extubation for a patient who is undergoing a compas-
sionate extubation, to guide anticipatory medication
dosing.
Elements of the Respiratory Distress Observation
Scale (RDOS) can be used to assess dyspnea during
the SBT and extubation process. The RDOS has
been validated as a surrogate for self-reported dyspnea
in palliative care in patients with impaired cognition
or decreased conscious levels.10 The RDOS has also
been found to significantly correlate with the
patient-reported dyspnea visual analog scale in the
ICU setting.11 It takes into account eight parameters:
heart rate, respiratory rate, accessory muscle use, par-
adoxical breathing pattern, restlessness, grunting at
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Ventilator Withdrawal in Anticipation of Death 167
the end of respiration, nasal flaring, and fearful facial
expression.
Modified SBT
The ventilator settings are changed to pressure sup-
port mode and patient is observed for clinical insta-
bility. This may include behavioral correlates of
respiratory distress including a fearful facial expres-
sion, accessory muscle use, paradoxical breathing,
and nasal flaring. Measurable signs may include an in-
crease or decrease in respiratory rate, tidal volume,
and heart rate. Based on the symptoms and signs
observed, opioids and/or benzodiazepines can be
titrated to achieve patient comfort before extubation.
This can serve as a guide to help the clinician antici-
pate the doses of medications that the patient might
need after extubation to maintain comfort. Once the
patient appears comfortable, proceed with the extuba-
tion. A step-by-step guide to physically performing an
extubation, as provided in the authors’ institution, can
be seen in Table 2.
Symptom Management During and After Extubation
Pain, Dyspnea. Opioids are the mainstay for dyspnea
and discomfort in the setting of compassionate extu-
bation.12 The doses of opioids used postextubation de-
pending on premorbid conditions, the dose of opioid
that the patient is receiving before extubation, and
dose titration during the SBT. The typical infusion
rate of morphine recommended by the American Col-
lege of Critical Care Medicine for critically ill patients
undergoing withdrawal of life-sustaining therapy is
0.05e0.5 mg/kg/hour, with typical iv boluses ranging
from 2 to 10 mg.12,13 Any time an increase in infusion
dose is being considered owing to worsening symp-
toms, bolus doses should be administered concur-
rently to achieve a rapid response.
Anxiety and Agitation. Anxiety is primarily managed
with benzodiazepines, beginning with as needed loraz-
epam or midazolam, with a low threshold to use drips
if needed. Depending on the antemortem diagnoses,
patients may benefit from premedication with a
benzodiazepine for its amnestic and sedative proper-
ties. Haloperidol is considered the drug of choice
for treatment of delirium in critically ill patients.12 It
reaches peak effect in approximately 30 minutes after
an intravenous dose and can be repeated every 15e
30 minutes as needed.
Excess Secretions. After removal of the endotracheal
tube, saliva and secretions may pool in the posterior
oropharynx and tracheobronchial tree, leading to rat-
tling sounds with inspiration and expiration. This phe-
nomenon, sometimes called the death rattle, tends to
occur in the terminal phase in patients who are too
168 Yeow and Chen Vol. 59 No. 1 January 2020

Table 2
Practical Step-by-Step Guide to Performing an Extubation
Place Wash-Cloth on Patient’s Chest, Have Oral Yankauer Suction Ready
Silence ventilator
For consideration: If patient has required aggressive suctioning for secretions, consider deep suctioning via ETT before extubation, can also
consider a dose of glycopyrrolate before extubation
Deflate cuff with 10 ml syringe and with one smooth move, remove ETT
Simultaneously turn off ventilator
Wrap ETT in washcloth and dispose
If tracheostomy in place, remove the ventilator tubing, leave tracheostomy in place
Gently suction oral cavity
For consideration: based on previous discussion with family, can consider placing oxygen by nasal cannula
ETT ¼ endotracheal tube.

weak or obtunded to adequately expectorate. It can be Simulation Cases

frequent, reported in between 23% and 90% of pa- Each simulation case was designed to focus on a
tients at the end of life. Although the death rattle is different teaching aspect of the compassionate extuba-
thought not to be extremely distressing to the patient, tion process. The cases increase in complexity as the
caregivers may experience distress that their loved one session proceeds. Case details may be elaborated
is choking. Repositioning to allow postural drainage before given to learners.
can be helpful, as can gentle oral suctioning. Deep
suctioning is not recommended once patient has
been extubated, as it can cause distress. Rather, family Case 1
members should be counseled that their loved one is Objectives
not distressed by the sounds of secretions. Anticholin-

Prepare a patient for withdrawal of life support;
ergic medications can also be used to decrease forma-
family does not wish to be present
tion of secretions: glycopyrrolate (by mouth or

Perform an SBT
intravenously), atropine (eye drops delivered sublin-

Titrate medications during the process of with-
gually), or transdermal scopolamine can be used.14e16
drawing ventilator support
Unless the patient is unconscious, atropine and

Remove an endotracheal tube and associated
scopolamine may increase the risk of delirium. Thus,
equipment
intravenous glycopyrrolate injections of 0.2 mg, 20 mi-
nutes before planned extubation then every Clinical Scenario. A 53-year-old woman presents to the
four hours as needed thereafter, are recommended. hospital with abdominal distension. She undergoes
emergency exploratory laparotomy and is found to
Paralytics. Neuromuscular blockade (also known as have diffuse peritoneal carcinomatosis. She develops
paralysis) is sometimes used to decrease ventilator dys- respiratory failure, renal failure, and line-induced fun-
synchrony in patients on mechanical ventilation. Pa- gemia. She is intubated and on continuous renal
tients appear comfortable as the facial muscles are replacement therapy.
relaxed and thus unable to show signs of distress. Pa- Owing to multiorgan failure in the setting of termi-
tients are unable to initiate their own breaths and all nal cancer, her family does not want to prolong her
breathing is triggered by the ventilator. Neuromus- suffering and decides to withdraw life support mea-
cular blockers provide no additional comfort to the sures. Family does not want to be in room at time of
patient and should not be initiated as a comfort mea- extubation. Patient is not responsive.
sure before ventilator withdrawal. In addition, if a Fellows are given her current vitals, ventilator set-
ventilator is withdrawn on a paralyzed patient, no tings, arterial blood gas values, and selected medica-
spontaneous breathing will ensue and the removal tions and infusions.
causes immediate death. If paralytics are being previ-
ously administered, ethically a provider should ensure Current
Vent Se ngs ABG, Vital Signs
Medica ons
that they are discontinued with enough time for the
• AC 15 • pH 7.50, PCO2 32, • Fentanyl g @ 25
patient to initiate their own breaths, unless there is a PO2 186 mcg/hr
• VT 550
contraindication or other compelling reason.17 Spon- • PEEP 10 • Monitor: RR 15, • Midazolam g @ 2
taneous breathing can be assessed visually, such as if • FiO2 60% HR 80 mg/hr
• Peak Pressure: 15 • Norepinephrine g
the patient is noted to be breathing over the venti- @ 10 mcg/min
lator, or a train-of-four can be checked. Train-of-four
uses a peripheral nerve stimulator to assess the depth
AC: Assist Control, VT: Tidal Volume, PEEP: Posi ve End Expiratory Pressure, FiO2:
of neuromuscular blockade, usually at the ulnar or Frac on of Inspired Oxygen
facial nerve.

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Vol. 59 No. 1 January 2020 Ventilator Withdrawal in Anticipation of Death 169

Critical Actions Critical Actions

Fellow follows algorithm to perform SBT

Fellow recognizes that pa ent is on a paraly c

Increase in respiratory rate and heart rate on monitor, nurse reports

increased use of accesory muscles, nasal flaring
Stops paraly c, allows me for pa ent to ini ate own breaths (ie overbreathing the set
vent rate OR checking train of four)

Fellows recognizes these as signs of distress, orders boluses of opioid and

benzodiazepine
Fellow recognizes that when a pa ent has unstable hemodynamics & high vent
se ngs, an SBT may not be clinically appropriate
Respiratory rate decreases , heart rate returns to baseline, and the nurse
reports that the paent appears more comfortable, but only aer mulple
boluses
Collabora ve decision with ICU team and family on the process of stopping the various
life sustaining measures
Fellow recognizes need to increase drip rates

Fellow follows algorithm to extubate paent

Case 2
Objective

Identify common ICU medications and infusions
that a critically ill patient may be using in the
setting of ventilator withdrawal

Manage a terminal extubation in a paralyzed
patient

Collaborate with the ICU team to facilitate with-
drawal of life support in a critically ill patient with un-
stable hemodynamics and high ventilator settings
Clinical Scenario. The palliative care consultant is
called to the burn unit to help with a patient who is
actively dying from extensive third-degree burns. He
is in multiorgan failure and acute respiratory distress
syndrome. He is hypotensive, requiring vasopressor
support, also on continuous renal replacement therapy.
His mother does not want to prolong his suffering
further and requests withdrawal of life-sustaining
treatment.
Fellows are given the vital signs, ventilator settings,
arterial blood gas values, and medications and infu-
sions. In this case, the patient is on high ventilator set-
tings and multiple drips.
Vent se ngs ABG, Vital Signs
• AC 24 • pH 7.30, PCO2 52, PO2
• VT 240 75
• PEEP 18 • Monitor: HR 80, RR 24
• Peak Pressure: 30
• FiO2 80%
Case 3
Objective

Prepare for ventilator withdrawal in a patient who
is awake and wishes to remain alert through the
process

Counsel a patient and family about expectations
during ventilator withdrawal, and whose spouse
remains present for extubation

Adjust ventilator settings, titrate medications, and
extubate the patient
Clinical Scenario. A 51-year-old woman is admitted to
ED with severe abdominal pain and found to have air
in her abdomen on imaging. She is taken emergently
to the OR and found to have a perforation from what
appeared to be a gastric mass, later confirmed to be
metastatic gastric adenocarcinoma. She is initially ex-
tubated after surgery, and given the news about the
diagnosis.
A few days later, she develops respiratory distress
and hypotension and was found to have acute respi-
ratory distress syndrome and gram-negative rod
sepsis. She is intubated, started on pressors and anti-
biotics. Even when intubated, she remains alert, ori-
Current Medica ons ented, and communicative via writing. After much
• Fentanyl g @ 150
tears and talks with her husband, she decides that
mcg/hr she wants to stop life-sustaining measures. She re-
• Midazolam g @ 4
mg/hr
quests to be as awake as possible after extubation.
• Norepinephrine g @ Her husband wishes to be present for the
10 mcg/min
• Vasopressin g @
extubation.
0.03 units/min The fellows are given the vital signs, ventilator set-
• Phenylephrine @ 100
mcg/min tings, arterial blood gases, and medications/drips. In
• Cisatracurium g @ 3 this case, her ventilator settings are moderate, and
mcg/kg/min
she has only one pressor at a very low rate.

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170 Yeow and Chen Vol. 59 No. 1 January 2020

Current Current
Vent Se ngs ABG, Vital Signs Vent Se ngs ABG, Vital signs
Medica ons Medica ons
• AC 14 • pH 7.4, PCO2 40, PO2 • Norepinephrine g • AC 15 • pH 7.50, PCO2 32, • Fentanyl g @ 25
• VT 450 90 @ 5 mcg/min • VT 550 PO2 186 mcg/hr
• PEEP 8 • Monitor: RR 16, • Morphine 2 mg IV • PEEP 10 • Monitor: RR 15, • Midazolam g @ 2
• FiO2 50% HR 70 push as needed (2 • FiO2 60% HR 80 mg/hr
• Peak Pressure: 15 doses used in past • Peak Pressure: 15 • Norepinephrine g
24 hours) @ 10 mcg/min
• Piperacillin-
Tazobactam

Critical Actions
Critical Actions
First 4 steps are idencal to Case 1

Fellow 1 counsels paent and husband, then performs SBT using algorithm
Fellow 1 performs extubaon, Fellow 2 reassures and provides support to
family member

Increase in RR and HR on monitor; paent with labored breathing , increased Post extubaon, loud gurgly respiraons occur
use of accessory muscles, nasal flaring and fearful expression on her face
Family member gets anxious and distressed

Response: Fellow 1 manages excess secreons with re -posioning and

Fellow 1 responds by giving small bolus of opioid, connually assessing paent medicaons Fellow 2 responds to the emoons of the distressed family
member
Fellow 2 reassures and provides support to husband

Excess secreons subside, paent appears comfortable

Decrease in RR an HR on monitor aer one dose of morphine Family member is less distressed
Paent also indicates that she is feeling beer, and appears more comfortable
Fellow recognizes that there is no need to start an infusion

Fellow 1 proceeds with extubaon; Fellow 2 responds to husband's emoons
and quesons
Case 4
Objective

Withdraw ventilator support with an anxious fam-
ily member present

Support and counsel an anxious family member
during and after the extubation process

Manage the symptoms that may occur after a
compassionate extubation
Clinical Scenario. This case includes clinical details
from Case 1, but with an anxious family member
who wishes to be present for the extubation. After
the extubation, the patient develops loud gurgly secre-
tions which escalate the family member’s anxiety and
emotions.
As in Case 1, the fellows are given her vitals, venti-
lator settings, arterial blood gases, and the medica-
tions and drips that she is on.
Debriefing
A 10-minute debriefing session is held with the
entire group after each case. The active participants
are first invited to reflect on their experience and
share their thoughts about how the simulation session
went. The observers then share their insights and feed-
back to the whole group. This session is facilitated by
the palliative faculty.
Discussion
Owing to the increasing frequency of withdrawal of
life support in a variety of settings, we designed a teach-
ing session that includes a one-hour didactic followed by
two hours of high-fidelity simulation to teach HPM fel-
lows the practical aspects of compassionate extubation.
We have run this session for the past four years and
have received positive feedback from most participants.
Feedback from prior years has been incorporated to
improve the experience for future learners. For
example, the session was moved from the midpoint of
the fellowship to the first month of the fellowship year,
given the importance of learning the content early in
the year to allow maximal opportunities for practical

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Vol. 59 No. 1 January 2020
application. In addition, time has been allotted at the
end of each case to allow each fellow an opportunity
to physically remove the endotracheal tube.
One of the biggest challenges we have faced is the
difference in experience and comfort level among
the palliative fellows with critically ill intubated pa-
tients and ventilators. We have had some fellows with
advanced ICU training and some with minimal experi-
ence with the intubated patient or ventilator knowl-
edge. We make an effort to assess the varying levels
of experience before the simulation cases and assign
the more straightforward cases to fellows with critical
care experience.
Moving forward, we see several potential areas for
growth and further development. Simulation lab
curricula could be designed to enhance HPM fel-
lows’ training in other procedural-based skills such
as palliative sedation and discontinuation of mechan-
ical circulatory devices such as left ventricular assist
devices and extracorporeal membranous oxygena-
tion circuits. In addition, the curriculum could be
expanded to enhance palliative education for ICU
clinicians. Here, the emphasis would be less on prac-
tical aspects of removing an endotracheal tube, but
rather focusing more on complex symptom manage-
ment during and after the compassionate extubation
process. Cases could also be designed to include
communication pearls on postextubation prognosti-
cation and counseling anxious family. This curricu-
lum could also be expanded to incorporate
learners from the interdisciplinary team who are
commonly involved in compassionate extubations
including nursing, respiratory therapy, and chap-
lains, among others. Implementation of presession
and postsession knowledge assessments could give
us more objective data on the value of such simula-
tion sessions.
Overall, this session has been very well received by
the participating HPM fellows. It shows that high-
fidelity simulation can be useful in palliative medicine
education. With collaboration among the simulation
lab staff and staff with Critical Care expertise, it is a
feasible endeavor.
Disclosures and Acknowledgments
The authors have no conflicts of interest to declare.
The authors would like to acknowledge the help of
Dr. Michelle Sergel, director of the Rush University
Medical Center Simulation Lab and the staff of the
Simulation Lab, who embraced this endeavor and
helped make this session a reality.
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Ventilator Withdrawal in Anticipation of Death 171
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