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Care of Intubated ED Patients at the End of Life (2.1.21)

Care of Intubated ED Patients at the End of Life (2.1.21) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.21


UW HEALTH CLINICAL POLICY 1
Policy Title: Care of Intubated ED Patients at the End of Life
Policy Number: 2.1.21
Category: UW Health
Type: Inpatient
Effective Date: October 25, 2016

I. PURPOSE

To outline a multi-disciplinary work-flow that safely transitions intubated patients with non-survivable injuries
and comfort measure only goals from the Emergency Department (ED) to a general care floor for end of life
care.

II. DEFINITIONS

End of life (EOL) patient: A person whose disease process cannot be cured or adequately treated and who
is expected to die within a short period of time without intervention.

End of life care: Support and medical care given during the time surrounding death.

III. POLICY ELEMENTS

A. This policy applies to End of Life (EOL) patients in the ED who meet the following criteria:
i. Patient is intubated (either intubated prior to arrival or while in the ED).
ii. Patient’s decision maker is present in person or has been contacted by phone, and has agreed to
stop life-sustaining measures and to immediately begin end of life care. (refer to UWHC policy
#4.17, Informed Consent)
a. If the plan is to wait for additional family or friends to arrive prior to initiating end of life
measures, (i.e., the terminal weaning and extubation process) the patient may be admitted
to the Intensive Care Unit (ICU).
iii. The physician has documented the decision to stop life-sustaining measures in the medical record.
a. Refer to UWHC policy #8.25, Guidelines for Decisions to Limit Life-Sustaining Medical
Treatment regarding the decision to end life-sustaining measures and physician
documentation of this decision.
iv. The UW Organ and Tissue Donation (UW OTD) has been contacted and has confirmed that this
patient cannot be a solid organ donor, or the family has denied donation through the designated
requestor. See UWHC policy #4.31, Organ and Tissue Donation.

IV. PROCEDURE

A. The physician shall discontinue all orders except for those relating to comfort care.
i. Order set IP – ED – End of Life Sustaining Measures in ED and ICU Patient – Adult –
Supplemental [3429] is available for use.
B. The intubated patient will be admitted to a general care nursing unit, either F4/4 or B6/6.
i. Trauma EOL patients will be admitted to F4/4 due to that unit’s staff familiarity with the trauma
patient population.
ii. All other (non-trauma) patients will be admitted to B6/6. If no beds are available on B6/6, then admit
to F4/4. Save Our Shift (SOS) nursing staff must accompany patients if transferred from the ED to
B6/6.
iii. If both F4/4 and B6/6 are full, a patient may be transferred off of F4/4 to make room for the EOL
patient.
iv. If both F4/4 and B6/6 are full and unable to accommodate the EOL patient, the patient may be
admitted to TLC, Neuro ICU or managed in the ED until a bed is available.
C. The Admitting service is the specialty service responsible for managing the body system that is causing the
patient’s death.
D. If the patient is transferred from the ED to either F4/4 or B6/6, the expected duration of delay before
extubation should not exceed approximately 2 hours. If the duration of delay is expected to be significantly
longer than 2 hours, the patient should be transferred to the ICU.
E. Respiratory Therapy will be responsible for ventilator wean and extubation on the general care floor.
F. Save Our Shift (SOS) nursing staff will provide nursing care until the patient is extubated and comfortable on
pain and/or sedation medications. At that point, unit nursing staff will take over care of the patient.



UW HEALTH CLINICAL POLICY 2
Policy Title: Care of Intubated ED Patients at the End of Life
Policy Number: 2.1.21

G. The patient will be transferred to the Palliative Care service at or soon after the extubation. If extubation
occurs off-hours (5:00 p.m. to 7:00 a.m.) the patient will stay on the primary service and the transfer to
Palliative Care will occur at 7:00 a.m. to minimize handoffs. The primary service must contact the palliative
care team to discuss transfer.
H. After death, refer to UWHC policy #4.21, Disposition of the Body after Death.

V. COORDINATION

Author: Medical Director, Emergency Medicine
Senior Management Sponsor: SVP, Medical Affairs
Reviewers: Medical Director of Neurocritical Care; Medical Director, Palliative Care; Nurse Manager,
Surgical Trauma Unit F4/4; Nurse Manager, Hematology, Oncology, & BMT; Nurse Manager, SOS; Director,
Emergency Services; CNS, Surgical Trauma Unit F4/4; CNS, Hematology, Oncology, & BMT; Respiratory
Therapy Supervisor
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: June 20, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

Order Set IP – ED – End of Life Sustaining Measures in ED and ICU Patient – Adult – Supplemental [3429]
UWHC policy #8.25, Guidelines for Decisions to Limit Life-Sustaining Medical Treatment
UWHC policy #4.31, Organ and Tissue Donation
UWHC policy #4.21, Disposition of the Body after Death
UWHC Respiratory Care Services departmental policy #2.02, Mechanical Ventilation: Adult and Pediatric
UWHC policy #4.17, Informed Consent

VIII. REVIEW DETAILS
Version: Original
Next Revision Due: October 2019