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Review
. 2023 Sep;66(3):e399-e426.
doi: 10.1016/j.jpainsymman.2023.05.009. Epub 2023 May 26.

Evidence Guiding Withdrawal of Mechanical Ventilation at the End of Life: A Review

Maria A Mazzu  1 , Margaret L Campbell  2 , Richard M Schwartzstein  3 , Douglas B White  4 , Susan L Mitchell  5 , Corey R Fehnel  6
Affiliations
Review

Evidence Guiding Withdrawal of Mechanical Ventilation at the End of Life: A Review

Maria A Mazzu et al. J Pain Symptom Manage. 2023 Sep.

Abstract

Objective: Distress at the end of life in the intensive care unit (ICU) is common. We reviewed the evidence guiding symptom assessment, withdrawal of mechanical ventilation (WMV) process, support for the ICU team, and symptom management among adults, and specifically older adults, at end of life in the ICU.

Setting and design: Systematic search of published literature (January 1990-December 2021) pertaining to WMV at end of life among adults in the ICU setting using PubMed, Embase, and Web of Science. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

Participants: Adults (age 18 and over) undergoing WMV in the ICU.

Measurements: Study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

Results: Out of 574 articles screened, 130 underwent full text review, and 74 were reviewed and assessed for quality. The highest quality studies pertained to use of validated symptom scales during WMV. Studies of the WMV process itself were generally lower quality. Support for the ICU team best occurs via structured communication and social supports. Dyspnea is the most distressing symptom, and while high quality evidence supports the use of opiates, there is limited evidence to guide implementation of their use for specific patients.

Conclusion: High quality studies support some practices in palliative WMV, while gaps in evidence remain for the WMV process, supporting the ICU team, and medical management of distress. Future studies should rigorously compare WMV processes and symptom management to reduce distress at end of life.

Keywords: Withdrawal of mechanical ventilation; end of life; intensive care unit; palliative care.

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Conflict of interest statement

Disclosures/Conflict of Interest: All authors have nothing to disclose.

Figures

Figure 1.
Figure 1.
Systematic Review Flow Diagram Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. http://www.prisma-statement.org/
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