Vent Withdrawal: Shared-Decision-Making Conversation Script

This conversation map includes specific phrases to use when talking to families whose loved ones are dying despite critical care support. All clinicians should check with their institution’s legal counsel to ensure compliance with federal and state laws as well as institutional protocols. You can also download an editable version of the script. Developed by VitalTalk.

Note: this script applies to shared decision-making standards of care, and is not intended for situations where crisis care triage standards apply.

Preview “Warning Shot" + Asking Permission: "I have some serious news to share with you. Would it be okay if we talk about it?”

Headline: “In the past few (hours/days) your loved one (has become more ill/has not improved). I am very worried about their chances of recovering. (Allow a pause for family to absorb this information). I wish things were different.”

State Clearly What You Will Do: “I want you to know that we will continue to use all available medical treatments that we think will help your loved one recover from this illness. We would like to talk again in (specify time), unless s/he has a change in condition sooner.”

If family asks (at this time) for critical care and/or ventilator use to continue:

2nd Headline: “I can see how worried you are. I want to reassure you that today I’m just calling to give you an update on your loved one’s condition and my concerns about how they are doing. I want to assure you that we are continuing to support him/her. I should mention that in some cases this illness worsens quite suddenly. We will continue to keep you updated. I would like to call you again later or tomorrow—is that ok?

Note: this script applies to shared decision-making standards of care, and is not intended for situations where crisis care triage standards apply.

Preview “Warning Shot" + Asking Permission: "I’m calling to follow up on our last conversation.vWould it be okay if we talk now?”

Headline, Part One: “In the past few (hours/days) your loved one has gotten worse. (Allow a pause for family to absorb this information). Their condition has worsened to the point where we need to change the course of our care.” (Allow a second pause.)

Headline, Part Two: “I’m calling to let you know that your loved one is dying now. We are recommending that we remove the ventilator and allow for a natural (or "peaceful" or "comfortable") death.

(Allow pause.)

I wish things were different.” (Allow a pause; respond to emotions – see below.)

State Clearly What You Will Do: “I want you to know we will focus our care on treating symptoms to ensure your loved one’s comfort and allow a peaceful death. We will pay close attention to shortness of breath, or any other signs of discomfort, and give medications and other treatments that help your loved one feel more comfortable. (Allow a pause for family to absorb this information). I wish things were different.”

Headline, Part Three: “Is it OK if I give you more information now about what to expect next? (Pause, and wait for permission to proceed.) People with this virus who are as sick as your ____ usually die quickly, possibly even within minutes to hours.” (Allow a pause; respond to emotions – see below. Explain your institution’s visiting policy for dying patients.)

Offer Support: “I want you to know that we are absolutely here to support you through this. Is there anything you can think of right now that would be helpful?” (If asked, explain your institution’s resources for support of these families, e.g., social work or chaplaincy, etc.)

Offer to talk family through the process of saying goodbye, and say that you will support them to do it by phone or iPad if they are not able to come in right away or are not allowed to visit in person because of hospital policy. See below for a script for helping families say goodbye to dying loved ones over the phone.

Responding to family concerns:

"I wish we had a treatment available that would help your family member recover. We will do our very best to make sure they are comfortable during the dying process.” (Allow a pause for family to absorb this information.)

“I wish things were different. This is an extraordinary time we all find ourselves in.”

“I can’t imagine how difficult this is for you and everyone else who loves (patient’s name).”

“You have been an incredible advocate for your loved one. I can see how deeply you care.”

Responding to family anger:

"It is understandable that you would be angry. I wish I had treatments available that would help him/her recover. We will stay committed to doing our very best for your loved one with the treatments focused on their comfort."

“It is understandable that you would be angry. I can see that you care about her/him a great deal. This is an extraordinary time we all find ourselves in.”

Responding to family grief/sadness:

“I want you to know that all of us here care deeply about your experience and your loved one’s experience right now.”

“I understand how difficult it is even under normal circumstances to have your loved one in an ICU. It must be unimaginably hard during this pandemic.”

Preview + Asking Permission: "Sometimes people wonder what to say when their loved one is dying. Is that something you are wondering about? Would it be helpful if I shared some things some people have found helpful?”

If yes, then: “Some of these things may apply to you, and others might not. There is no order, and you can use any of these five things that feel right to you. We think that even though your loved one is sedated and comfortable, that many patients retain their ability to hear, even when they are unconscious. So if you wish, this is the time to say goodbye. These are the five things to consider saying. You might want to write them down.”

1. Please forgive me (for anything I may have done that caused you pain).
2. I forgive you.
3. I love you.
4. Thank you (for being my father…).
5. Goodbye.

Many patients worry about their families and whether they will be okay after they die. It helps some patients to be reassured that their family will take care of one another after the patient dies.