End of life care and withdrawal of NIV

Conducting the withdrawal of NIV

Although each case will vary, the withdrawal of non-invasive ventilation (NIV) is likely to lead to breathlessness and distress. These symptoms may be rapid so professionals should anticipate, plan and effectively manage them.

By law within the judgement of Bodkin Adams in 1957:

If the purpose of medicine, the restoration of health, can no longer be achieved there is still much for a doctor to do, and he is entitled to do all that is proper and necessary to relieve pain and suffering, even if the measures he takes may incidentally shorten life. (R v Bodkin Adams, 1957, CLR 365)

Therefore, professionals are able to support patients to relieve pain, discomfort and distress.

Symptom management should be tailored to the individual patient. Factors that may influence the plan include:

How quickly the patient becomes distressed without assisted ventilation
Choice of drugs
What drugs the patient is already on
Which route of administration the clinical team feel confident with
Who is administering medication
The preferences of the patient and family
The ease of venous cannulation

Patients who are highly dependent on NIV and become very breathless or distressed within minutes when not using NIV will require sedation before the NIV is withdrawn. It is important that the level of sedation is adequate before the NIV is removed to prevent distress. This can be assessed by reducing or stopping the ventilation for a short time, reinstating it with adjustment of medication as necessary.

Patients who can tolerate longer periods of time without NIV will develop symptoms after a longer period of time and will require augmented symptom control. These patients will require medication that allows them to remain calm comfortable and mildly drowsy without being deeply sedated.

Sedatives and painkillers help relieve breathlessness and anxiety.

Opioids such as morphine and diamorphine should be used to manage breathlessness.

Benzodiazepines such as midazolam and lorazepam should be used to manage distress.

Medications to reduce nausea and sickness - prochlorperazine mesilate and metoclopramide.

When planning the withdrawal of NIV, it is important to consider the positioning of the patient as sitting up may help ease breathlessness.

A minimum of three professionals are needed to be at the withdrawal of NIV because one person is needed to manage the ventilator, one person is needed to manage the symptoms and one person should be present to support the family.

More guidance on conducting the withdrawal of NIV and symptom control

In the following clip, Matt Cox discusses steps that they take to manage the ventilation at withdrawal to make it less distressing for the family members.

Good practice points

Symptoms of breathlessness and distress should be anticipated, planned and managed effectively.
The management of breathlessness and anxiety will require an individualised approach.
A minimum of three healthcare professionals should be present at withdrawal.
Support should be provided for the patient’s family members.