Friday, May 31, 2013

Pulling the Plug on a Ventilator

A while back, I was sent the following scenario by an author who asked me to comment on the reality of the situation. 

An elderly Alzheimer's patient with a valid Do Not Resuscitate order is hooked up to a mechanical ventilator (also called a respirator) in the ER by hospital staff who are unaware of the DNR order. The patient is transferred to the ICU where a doctor confirms the existence of the DNR order. The patient is left on the ventilator, but a DNR sign is taped above the man's bed. 

The next-of-kin arrives at the hospital and unplugs the ventilator without discussing her actions with the ICU staff. The book's heroine rushes into the room and attempts to restart the ventilator by plugging the electrical cord back into the wall socket. The relative lunges at the heroine, preventing her from reaching the outlet. Then an ICU nurse arrives and stops both women from any further action. "You can't do that,"  the nurse tells the heroine while pointing to the DNR sign over the bed. "That mean you can't plug it in."

The author of this scenario wanted to know if the next-of-kin could simply unplug the machine as in the story, or if she could order the staff to do it. Would the patient die immediately? Would the DNR order cover this situation, thus preventing anyone from restarting the ventilator?

First of all, the relative could be in big trouble if she pulled the plug. Without a Power of Attorney for Health Care to back her actions, she could be charged with either manslaughter or murder -- depending on the decision of the state's attorney -- if the patient died. Even with such a legal form in hand, she wouldn't be allowed to simply turn off the machine. Instead, she'd have to inform the doctor of the patient's wishes as stated in the POA and request that the ventilator be shut down. Once the POA is presented, the doctor would be required to do as asked and order the ventilator removed. 

As for what the nurse said in this scenario -- "you can't plug it in" -- most experienced nurses wouldn't reply in that manner if faced with such a situation. I believe what would happen is this: The nurse would hit the code button, thus bringing other staff running to the room. She would quickly tell those present what had happened, ask one person to clear the room of visitors (the relative and the heroine), ask another to contact the ICU resident and the patient's doctor, and do all this while disconnecting the intubation tube from the ventilator and reconnecting it to an Ambu bag minus the mask. The nurse would ventilate the patient using the Ambu bag until the resident or patient's doctor arrived. It would be up to the doctor to decide if there is a legal and/or ethical reason to discontinue ventilation, given the presence of the DNR order and the next-of-kin's demands.

People are placed on ventilators for a variety of health reasons. Patients with congestive heart failure, COPD, asthma, or other related lung disorders are often placed on ventilators for 1-3 days until their conditions can be stabilized. Some remain ventilated for longer than that, but are eventually weaned from the ventilator and go home breathing on their own.

Patients who suffer cardiac arrest and are initially treated with cardiopulmonary resuscitation (CPR) generally face intubation, either by paramedics on the scene or on arrival in an ER. The value of CPR lies in its use within minutes of the arrest, before the brain is depleted of oxygen and begins to die. Patients who suffer massive strokes or head trauma affecting the ability of their brains to control their breathing are also intubated and placed on ventilators. 

The decision to stop mechanical ventilation is based on several factors. Medical testing may show lack of brain function in the patient; the brain is too damaged to recover from trauma, stroke, or cardiac arrest. The family may present a legal DNR form or POA form stating the patient's desire not to have his life prolonged by intubation. Even without such forms, consultation with the family may result in a decision to withdraw mechanical assistance if it's judged to be of no value in returning the patient to some level of function. 

As for the author asking if death would occur immediately after cessation of ventilation, my answer must be imprecise. Some patients die within minutes of removal from a ventilator. Others linger for several hours, unconscious but still with some respiratory activity. It all depends on the level of brain function, the ability of the heart to circulate oxygen, and the ability of the respiratory muscles to sustain breathing, all of which are related to the underlying cause of the patient's condition, be it trauma or disease.

More on DNR orders, POA forms, and the newer POLST forms next week here at Cicero's Children. This is all good information for authors seeking to write realistic medical scenes. It's also great information for those of us who wish to control our future medical care. Why leave all the decisions in other people's hands? Doing that doesn't make sense, does it?



  1. Very good information! Thanks!

  2. Also, Mary, don't most modern ventilators have battery back up? (as do pump IVs). Pulling the plug wouldn't necessarily cut off the ventilator. Plus, two patients visiting in ICU at once is also pretty unusual. Just some added info from a long time and now retired RN. :-)

  3. Thanks for this. Very handy to know.

  4. Thanks for all your comments, everyone! And yes, Leann, you're right about the battery backup, which I totally forgot when writing this blog. :) Also, the ventilator alarm would have sounded immediately, and that usually brings a nurse running. The ICU's in the two hospitals where I worked allowed two visitors per patient, but only for a limited time. When my sister was in ICU at another hospital -- one where I didn't work -- it seemed like anyone could walk in at any time. I actually had to turn people away from my sister's room -- she was in such serious condition, she certainly didn't need 3 or 4 people wanting to walk in at the same time. Seems to me that some hospitals act more like hotels, afraid to discourage "clients".