When a patient is on life support in a hospital, it means they require machines to help keep them alive. Life support can include ventilators to assist with breathing, IV fluids and medication, cardiac monitors, and other equipment. If a patient on life support deteriorates to the point where the machines are the only things keeping them alive, doctors may make the decision with the family to withdraw life support. This is an extremely difficult decision for families to make, and the process does not necessarily mean the patient will pass away immediately.
Why is the decision made to withdraw life support?
There are a few key reasons why a doctor may recommend withdrawing life support:
- The patient has a terminal illness that has progressed to the point that machines are simply prolonging the dying process
- The patient is in a vegetative state or coma with little to no brain activity or chance of recovery
- The patient’s organs are failing despite being on life support
- The patient has a written advance directive refusing life-sustaining treatment in certain circumstances
In these situations, the medical team determines that the life support is not helping or curbing the underlying condition – it is simply postponing death while the body continues to decline. Removing life support does not aim to end a life, but to avoid needlessly prolonging pain and suffering when there is little to no hope of recovery.
What happens once the decision is made?
The process begins with the patient’s medical team having an in-depth discussion with the family about the prognosis and reasons for withdrawing life support. Together they agree on a plan to discontinue treatment. Here are the typical steps:
- Equipment like ventilators and cardiac monitors are turned off and IV medications stopped.
- Tube feedings providing nutrition and hydration are halted.
- The patient is kept comfortable with pain medications.
- Oxygen, suction, and other bedside comfort care continues.
- The patient is allowed to pass away naturally without machines artificially prolonging life.
The patient is kept in a private room with family support available. Nurses continue providing compassionate end-of-life care to manage any discomfort. This process allows death to occur in a peaceful, dignified manner.
How long does the process take?
There is no specific timeline for how long it takes a patient to pass away after removing life support. Each situation is unique based on the individual’s underlying condition. Some patients may pass within minutes to hours after discontinuing mechanical ventilation and medications. For others it may take days to weeks for death to occur without the life support machinery.
According to studies, around 88% of critically ill patients in ICUs passed away within 24 hours after life sustaining therapies were withdrawn. About 7% survived longer than 1 week. Factors impacting the length of time include:
- The severity of the initial illness or injury
- Co-existing medical conditions
- Amount of organ failure
- If breathing can be maintained without ventilation
- Level of sedation or consciousness
Younger patients who were otherwise healthy aside from an acute injury or illness may live longer without life support compared to the elderly or those with chronic, terminal diseases. Patients in a persistent vegetative state may survive the longest without treatment.
What symptoms are seen?
When life support stops, certain signs and symptoms typically occur as the body begins shutting down. These may include:
- Changes in breathing patterns – slow, irregular, labored
- Decreased blood pressure
- Falling oxygen saturation levels
- Increased heart rate initially, then slowing
- Cooling of extremities as circulation decreases
- Mottling of skin color from circulatory changes
- Loss of urinary output as kidneys fail
- Unresponsiveness as consciousness declines
Movement and reflexes also slow as the patient becomes unresponsive. However, hearing is believed to be the last sense to be lost. Families are encouraged to sit with their loved one through the process, holding their hand and offering reassuring words. Even when seemingly unresponsive, the sound of a familiar voice can be comforting.
Will there be pain or suffering?
A major concern for families is whether their loved one will experience pain, air hunger, or emotional distress when life support stops. Rest assured every effort is made to prevent suffering and make the patient comfortable:
- Medications are given to reduce pain, anxiety, and shortness of breath
- Sedation can be increased to prevent air hunger if needed
- Supplemental oxygen maintains comfort even without machines
- Families provide comfort with their presence and words
Studies show most patients show no visible signs of distress when mechanical ventilation is removed. They appear peaceful and comfortable thanks to the medications on board. Any signs of discomfort are immediately treated by healthcare staff.
Will the patient be hungry or thirsty?
Since tube feedings and IV fluids are discontinued during the process, families may be concerned their loved one will have sensations of hunger or thirst. However, research indicates this is highly unlikely. In the final stages of life, the body’s metabolism changes. The need or desire for food and drink diminishes as the systems begin to shut down.
The mouth is kept moist with gentle swabbing, lip balm, and ice chips if desired. This gives comfort without artificially prolonging hydration while the patient is unable to swallow. Rest assured hunger and thirst are not perceived experiences at this point.
When is the time of death declared?
Diagnosing death once life support is removed depends on assessing for key criteria doctors refer to as cardiac death and brain death. Cardiac death is when the heart stops beating and circulation ceases. Brain death is when the brain irreversibly stops functioning.
To determine when death has occurred after withdrawing life support, doctors perform a clinical exam looking for absence of:
- Heartbeat and pulse
- Breathing
- Brainstem reflexes like gag, cough, and pupil response
- Response to pain stimuli
They also review data from machines monitoring heart rate and oxygen levels for patterns confirming cessation of circulation. Two physicians must separately confirm death has occurred using these objective criteria.
Time of death is declared when there is both loss of cardiac function and brain activity. This may occur within minutes, hours, or days after removing life support, depending on the patient’s condition.
What happens after death is declared?
Once life support withdrawn and death declared, the usual post-mortem processes ensue:
- Hospital staff stop all treatments aside from comfort care
- The patient’s body is cleaned and prepared
- The family can have additional private time with their loved one
- The body is transferred to mortuary services
- An autopsy may be done if needed to confirm cause of death
- The death certificate is signed confirming time and cause
- The family can proceed with funeral arrangements
Withdrawing life support is an emotional process for grieving families to go through. Hospital staff and social services provide support and guidance through every step. The main priorities are ensuring the patient’s comfort while giving loved ones a meaningful chance to say goodbye.
Conclusion
When a patient’s condition is irreversible and hopeless despite aggressive life support in an ICU, the decision to withdraw treatment is often a humane and appropriate one. Turning off machines like ventilators does not necessarily immediately end a life, but it does remove artificial barriers preventing natural death from occurring gently and peacefully. With proper palliative medications on board to prevent discomfort and families nearby to comfort with their loving presence, patients can transition with dignity when mechanical life support is removed after a critical illness or devastating injury.