Elective discontinuation of life-sustaining mechanical ventilation on a chronic ventilator unit

Care of the Patient Nearing the End of Life in the Neurointensive Care Unit

BACKGROUND

Neurologically critically ill patients present with unique disease trajectories, prognostic uncertainties, and challenges to end-of-life (EOL) care. Acute brain injuries place these patients at risk for underrecognized symptoms and unmet EOL management needs, which can negatively affect their quality of care and lead to complicated grief in surviving loved ones. To care for patients nearing the EOL in the neurointensive care unit, health care clinicians must consider neuroanatomic localization, barriers to symptom assessment and management, unique aspects of the dying process, and EOL management needs.

AIM

We aim to define current best practices, barriers, and future directions for EOL care of the neurologically critically ill patient.

Observations from Optimizing an Electronic Order Set for Withdrawal of Life-Sustaining Treatment

Background: Withdrawal of life-sustaining treatment (WLST) is a process with unique pressure for all involved. The use of an electronic order set can facilitate best care. Objective: To assess utilization of a WLST order set and time to inpatient death before and after optimization. Design: A retrospective chart review for 12-month periods before and after enhancements to a WLST order set. Setting/Subjects: Multicenter study within an American, not-for-profit health care system of inpatient decedents July 2017-June 2018 and April 2021-March 2022 with orders placed via WLST order set. Measurements: Co-primary outcomes included order set utilization and time from activation of orders to patient death. Descriptive post hoc analyses featured demographics, palliative consultation, ordering clinician type/specialty, and COVID-19. Results: A total of 1949 patients had orders placed via the WLST order set and died in-hospital. Compared with the 2017-2018 period, use increased 35.8% in 2021-2022. Time to death after release of orders was significantly longer for the 2021-2022 group (4.4 vs. 3.7 hours). Demographic details included nurse practitioners (39%) as most frequent WLST order set utilizer and palliative consultation in 46% of terminal hospitalizations. Among decedents with consultation, palliative clinicians were the WLST order set utilizer for 47% of cases (i.e., 21% of all WLST order set utilizations). The median time to death was significantly longer when orders were placed by a palliative clinician (4.5 hours) compared with nonpalliative specialists (3.9 hours). COVID-19 was a hospital diagnosis for 29% of decedents in the 2021-2022 group. Conclusions: In the emotionally and cognitively intense process that is WLST, an order set provides a modifiable panel of defaults. Our experience highlights the power in guiding primary palliative care for WLST in the hospital setting and suggests that advanced practice providers and nonpalliative clinicians, as primary utilizers, be integral in the design of a WLST order set.

Long-term mechanical ventilation and transitions in care: A narrative review

OBJECTIVES

Individuals dependent on long-term mechanical ventilation (LTMV) for their day-to-day living are a heterogenous population who go through several transitions over their lifetime. This paper describes three transitions: 1) institution/hospital to community/home, 2) pediatric to adult care, and 3) active treatment to end-of-life for ventilator-assisted individuals (VAIs).

METHODS

A narrative review based on literature and the author's collective practical and research experience. Four online databases were searched for relevant articles. A manual search for additional articles was completed and the results are summarized.

RESULTS

Transitions from hospital to home, pediatric to adult care, and to end-of-life for VAIs are complex and challenging processes. Although there are several LTMV clinical practice guidelines highlighting key components for successful transition, there still exists gaps and inconsistencies in care. Most of the literature and experiences reported to date have been in developed countries or geographic areas with funded healthcare systems.

CONCLUSIONS

For successful transitions, the VAIs and their support network must be front-and-center. There should be a coordinated, systematic, and holistic plan (including a multi-disciplinary team), life-time follow-up, with bespoke consideration of jurisdiction and individual circumstances.

End-of-Life Decisions of Intracranial Hemorrhage Patients Successfully Weaned From Prolonged Mechanical Ventilation

Factors related to the end-of-life decisions of patients with intracranial hemorrhage who were successfully weaned from prolonged mechanical ventilation remain unclear. This study aimed to evaluate factors that influence the end-of-life decisions of these patients.

METHODS

This retrospective study examined patients with intracranial hemorrhage successfully weaned from prolonged mechanical ventilation between January 2012 and December 2017. The following data was collected and analyzed: age, gender, comorbidities, Glasgow Coma Scale scores, receipt or non-receipt of intracranial hemorrhage surgery, discharge status, and end-of-life decisions.

RESULTS

In total, 91 patients with intracranial hemorrhage were successfully weaned from prolonged mechanical ventilation. The families of 62 (68.1%) patients signed the do-not-resuscitate order. A Glasgow Coma Scale score of ≥10 at discharge from the respiratory care center and zero comorbidities were the influencing factors between patients whose do-not-resuscitate orders were signed and those whose orders were not signed. Patients with intracranial hemorrhage successfully weaned from prolonged mechanical ventilation had chronic kidney disease comorbidity and Glasgow Coma Scale score of <7 on admission to respiratory care center with a general ward mortality rate of 83.3%.

CONCLUSIONS

The families of intracranial hemorrhage patients with multiple comorbidities and higher neurologic impairment after successful weaning from the ventilator believed that palliative therapy would provide a greater benefit. Patients with intracranial hemorrhage successfully weaned from prolonged mechanical ventilation with chronic kidney disease comorbidity and Glasgow Coma Scale score of <7 on admission to respiratory care center are candidates for the consideration of hospice care with ventilator withdrawal.

Incidence and Risk Model Development for Severe Tachypnea Following Terminal Extubation

BACKGROUND

Palliative ventilator withdrawal (PVW) in the ICU is a common occurrence.

RESEARCH QUESTION

The goal of this study was to measure the rate of severe tachypnea as a proxy for dyspnea and to identify characteristics associated with episodes of tachypnea.

STUDY DESIGN AND METHODS

This study assessed a retrospective cohort of ICU patients from 2008 to 2012 mechanically ventilated at a single academic medical center who underwent PVW. The primary outcome of at least one episode of severe tachypnea (respiratory rate > 30 breaths/min) within 6 h after PVW was measured by using detailed physiologic and medical record data. Multivariable logistic regression was used to examine the association between patient and treatment characteristics with the occurrence of a severe episode of tachypnea post extubation.

RESULTS

Among 822 patients undergoing PVW, 19% and 30% had an episode of severe tachypnea during the 1-h and 6-h postextubation period, respectively. Within 1 h postextubation, patients with the following characteristics were more likely to experience tachypnea: no pre-extubation opiates (adjusted OR [aOR], 2.08; 95% CI, 1.03-4.19), lung injury (aOR, 3.33; 95% CI, 2.19-5.04), Glasgow Coma Scale score > 8 (aOR, 2.21; 95% CI, 1.30-3.77), and no postextubation opiates (aOR, 1.90; 95% CI, 1.19-3.00).

INTERPRETATION

Up to one-third of ICU patients undergoing PVW experience severe tachypnea. Administration of pre-extubation opiates (anticipatory dosing) represents a key modifiable factor that may reduce poor symptom control.

Existential decision-making in a fatal progressive disease: how much do legal and medical frameworks matter?

BACKGROUND

Healthcare legislation in European countries is similar in many respects. Most importantly, the framework of informed consent determines that physicians have the duty to provide detailed information about available therapeutic options and that patients have the right to refuse measures that contradict their personal values. However, when it comes to end-of-life decision-making a number of differences exist in the more specific regulations of individual countries. These differences and how they might nevertheless impact patient's choices will be addressed in the current debate.

MAIN TEXT

In this article we show how the legal and medical frameworks of Germany, Poland and Sweden differ with regard to end-of-life decisions for patients with a fatal progressive disease. Taking Amyotrophic Lateral Sclerosis (ALS) as an example, we systematically compare clinical guidelines and healthcare law, pointing out the country-specific differences most relevant for existential decision-making. A fictional case report discusses the implications of these differences for a patient with ALS living in either of the three countries. Patients with ALS in Germany, Poland and Sweden are confronted with a similar spectrum of treatment options. However, the analysis of the normative frameworks shows that the conditions for making existential decisions differ considerably in Germany, Poland and Sweden. Specifically, these differences concern (1) the legal status of advance directives, (2) the conditions under which life-sustaining therapies are started or withheld, and (3) the legal regulations on assisted dying.

CONCLUSION

According to the presented data, regulations of terminating life-sustaining treatments and the framework of "informed consent" are quite differently understood and implemented in the legal setting of the three countries. It is possible, and even likely, that these differences in the legal and medical frameworks have a considerable influence on existential decisions of patients with ALS.

Determinants of Receiving Palliative Care and Ventilator Withdrawal Among Patients With Prolonged Mechanical Ventilation

OBJECTIVES

Increasing numbers of patients with prolonged mechanical ventilation generates a tremendous strain on healthcare systems. Patients with prolonged mechanical ventilation suffer from long-term poor quality of life. However, no study has ever explored the willingness to receive palliative care or terminal withdrawal and the factors influencing willingness.

DESIGN

Cross-sectional study.

SETTING

Five different hospitals of Taipei City Hospital system.

PATIENTS

Adult patients with ventilatory support for more than 60 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified the family members of 145 consecutive patients with prolonged mechanical ventilation in five hospitals of Taipei City Hospital system and enrolled family members for 106 patients (73.1%). We collected information from patient families' regarding concepts (knowledge, attitude, and experiences) of palliative care, caregiver burden, family function, patient quality of life, and physician-family communications. From the medical record, we obtained duration of hospitalization, consciousness level, disease severity, medical cost, and the presence of do-not-resuscitate orders. The vast majority of family members agreed with the concept of palliative care (90.4%) with 17.3% of the family members agreeing to ventilator withdrawal currently and 67.5% terminally in anticipation of death. Approximately half of the family members regretted having chosen prolonged mechanical ventilation (56.7%). Reduced patient quality of life and increased family understanding of palliative care significantly associated with increased caregiver willingness to endorse palliative care and withdraw life-sustaining agents in anticipation of death. Longer duration of ventilator usage and hospitalization was associated with increased feelings of regret about choosing prolonged mechanical ventilation.

CONCLUSIONS

During prolonged mechanical ventilation, physicians should thoroughly discuss its benefits and burdens. Families should be given the opportunity to discuss the circumstances under which they might request the implementation of palliative care or withdrawal of mechanical ventilation in order to avoid prolonging the dying process.

How Long Does (S)He Have? Retrospective Analysis of Outcomes After Palliative Extubation in Elderly, Chronically Critically Ill Patients

OBJECTIVE

For chronically critically ill elderly patients on mechanical ventilation, prognosis for significant recovery may be minimal. These individuals, or their surrogates, may decide for "palliative extubation." A common prognostic question arises: "How long does she/he have?" This study describes demographics, mortality, time to death, and factors associated with death after palliative extubation.

DESIGN, SETTING, AND PATIENTS

Retrospective 3-year study in community hospital with ethnically diverse elderly population. Chronically critically ill patients followed from palliative extubation to death or survival to discharge.

MEASURES

Mortality/survival following palliative extubation, time to death or discharge, factors associated with death.

RESULTS

Hundred and forty-eight subjects underwent palliative extubation. Mean age: 78 years, 60% female, ethnically diverse with 46% white, and 54% others. Top diagnostic categories: sepsis (47%) and respiratory failure (22%). After extubation, 114 patients (77%) died in hospital and 34 (23%) were discharged. Of those who died, median time to death 8.9 hours (range, 4 min to 7 d). Mortality proportion was 56% at 24 hours and increased with time. Factors associated with early death: Systolic blood pressure less than 90 (p = 0.002) and Charlson Comorbidity Index that is above 6 or 0 (p = 0.002).

CONCLUSIONS

Palliative extubation at end of life was an option selected by an ethnically diverse elderly population. Approximately three-fourths of subjects died in hospital, and one-fourth was discharged alive. Over 50% who died did so within 24 hours, making this useful information for counseling and anticipatory planning. Subjects with systolic blood pressure less than 90 and Charlson Comorbidity Index that is very low or very high had higher mortality.

How is life support withdrawn in intensive care units: A narrative review

PURPOSE

Decisions to withdraw life-sustaining therapy (WDLS) are relatively common in intensive care units across Canada. As part of preliminary work to develop guidelines for WDLS, we performed a narrative review of the literature to identify published studies of WDLS.

MATERIALS AND METHODS

A search of MEDLINE and EMBASE databases was performed. The results were reviewed and only articles relevant to WDLS were included. Any references within these articles deemed to be relevant were subsequently included.

RESULTS

The initial search identified 3687 articles. A total of 100 articles of interest were identified from the initial search and a review of their references. The articles were primarily composed of observational data and expert opinion. The information from the literature was organized into 6 themes: preparation for WDLS, monitoring parameters, pharmacologic symptom management, withdrawing life-sustaining therapies, withdrawal of mechanical ventilation, and bereavement.

CONCLUSIONS

This review describes current practices and opinions about WDLS, and also demonstrates the significant practice variation that currently exists. We believe that the development of guidelines to help increase transparency and standardize the process will be an important step to ensuring high quality care during WDLS.

Discontinuance of life sustaining treatment utilizing ketamine for symptom management

We present the case of an otherwise healthy 21-year-old female who developed severe respiratory failure following a minor procedure requiring ECMO and bi-level ventilation. During her protracted ICU course, she had significant difficulties with agitation and was titrated to the following regimen: hydromorphone 30 mg/hour, fentanyl 200 mcg/hour, dexmedetomidine 1.5 mcg/kg/hour, propofol at 70 mcg/kg/min, and midazolam at 20 mg/hour. We were consulted to assist in withdrawal of life prolonging measures at the family's request and given high doses of commonly used opioid and sedative medications successfully utilized methadone and ketamine for symptom control. This case study would indicate that in selected patients on high dose opioid and sedative medications prior to withdrawal of life prolonging measures ketamine may be considered for symptom management.

The Durban World Congress Ethics Round Table Conference Report: III. Withdrawing Mechanical ventilation--the approach should be individualized

PURPOSE

The purpose of this study is to determine the approaches used in withdrawing mechanical ventilator support.

MATERIALS AND METHODS

Speakers from the invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were asked to provide a detailed description of individual approaches to the process of withdrawal of mechanical ventilation.

RESULTS

Twenty-one participants originating from 13 countries, responded to the questionnaire. Four respondents indicated that they do not practice withdrawal of mechanical ventilation, and another 4 indicated that their approach is highly variable depending on the clinical scenario. Immediate withdrawal of ventilation was practiced by a large number of the respondents (7/16; 44%). A terminal wean was practiced by just more than a third of the respondents (6/16; 38%). Extubation was practiced in more than 70% of instances among most of the respondents (9/17; 53%). Two of the respondents (2/17; 12%) indicated that they would extubate all patients, whereas 14 respondents indicated that they would not extubate all their patients. The emphasis was on tailoring the approach used to suit individual case scenarios.

CONCLUSIONS

Withdrawing of ventilator support is not universal. However, even when withdrawing mechanical ventilation is acceptable, the approach to achieve this end point is highly variable and individualized.

[Palliative care in patients without cancer: Impact of the end-of-life care team]

Palliative care improves the quality of life of patients and their families facing problems associated with life-threatening illnesses by promoting the prevention and relief of suffering. Palliative care in Japan has been developed mainly for cancer patients. At the National Center for Geriatrics and Gerontology, an end-of-life care team (EOLCT) has been developed to promote palliative care for patients without cancer. In the first 6 months of its operation, 109 requests were received by the team, 40% of which were for patients without cancer or related disease, including dementia, frailty due to advanced age, chronic respiratory failure, chronic heart failure, and intractable neurologic diseases. The main purpose of the EOLCT is to alleviate suffering. The relevant activities of the team include the use of opioids, providing family care, and giving support in decision-making (advance care planning) regarding withholding; enforcement; and withdrawal of mechanical ventilators, gastric feeding tubes, and artificial alimentation. The EOLCT is also involved in ongoing discussions of ethical problems. The team is actively engaged in the activities of the Japanese Geriatric Society and contributes to the development of decision-making guidelines for end-of-life by the Ministry of Health, Labour and Welfare. The EOLCT can be helpful in promoting palliative care for patients with diseases other than cancer. The team offers support during times of difficulty and decision-making.

The infusion of opioids during terminal withdrawal of mechanical ventilation in the medical intensive care unit

CONTEXT

Most deaths in intensive care units occur after limitation or withdrawal of life-sustaining therapies. Often these patients require opioids to assuage suffering; yet, little has been documented concerning their use in the medical intensive care unit.

OBJECTIVES

To determine the dose and factors influencing the use of opioids in patients undergoing terminal withdrawal of mechanical ventilation in this setting.

METHODS

Data were prospectively collected from 74 consecutive patients expected to die soon after extubation. The doses of morphine, effect on time to death, and relation of dose to diagnostic categories were analyzed.

RESULTS

The mean (±standard deviation) dose of morphine given to patients during the last hour of mechanical ventilation was 5.3mg/hour. Patients dying after extubation received 10.6 mg/hour just before death. Immediately before extubation, the dose correlated directly with chronic medical opioid use and sepsis with respiratory failure and inversely with coma after cardiopulmonary resuscitation or a primary neurological event. After terminal extubation, the final morphine dose correlated directly with the presence of sepsis with respiratory failure and chronic pulmonary disease. The mean time to death after terminal extubation was 152.7 ± 229.5 minutes without correlation with premorbid diagnoses. After extubation, each 1mg/hour increment of morphine infused during the last hour of life was associated with a delay of death by 7.9 minutes (P = 0.011).

CONCLUSION

Premorbid conditions may influence the dose of morphine given to patients undergoing terminal withdrawal of mechanical ventilation. Higher doses of morphine are associated with a longer time to death.

Deciding in the dark: advance directives and continuation of treatment in chronic critical illness

OBJECTIVE

Chronic critical illness is a devastating syndrome for which treatment offers limited clinical benefit but imposes heavy burdens on patients, families, clinicians, and the health care system. We studied the availability of advance directives and appropriate surrogates to guide decisions about life-sustaining treatment for the chronically critically ill and the extent and timing of treatment limitation.

DESIGN

Prospective cohort study.

SETTING

Respiratory Care Unit (RCU) in a large, tertiary, urban, university-affiliated, hospital.

PATIENTS

Two hundred three chronically critically ill adults transferred to RCU after tracheotomy for failure to wean from mechanical ventilation in the intensive care unit.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We interviewed RCU caregivers and reviewed patient records to identify proxy appointments, living wills, or oral statements of treatment preferences, resuscitation directives, and withholding/withdrawal of mechanical ventilation, nutrition, hydration, renal replacement and vasopressors. Forty-three of 203 patients (21.2%) appointed a proxy and 33 (16.2%) expressed preferences in advance directives. Do not resuscitate directives were given for 71 patients (35.0%). Treatment was limited for 39 patients (19.2%). Variables significantly associated with treatment limitation were proxy appointment prior to study entry (time of tracheotomy/RCU transfer) (odds ratio = 6.7, 95% confidence interval [CI], 2.3-20.0, p = 0.0006) and palliative care consultation in the RCU (OR = 40.9, 95% CI, 13.1-127.4, p < 0.0001). Median (interquartile range) time to first treatment limitation was 39 (31.0-45.0) days after hospital admission and 13 (8.0-29.0) days after RCU admission. For patients dying after treatment limitation, median time from first limitation to death ranged from 3 days for mechanical ventilation and hydration to 7 days for renal replacement.

CONCLUSIONS

Most chronically critically ill patients fail to designate a surrogate decision-maker or express preferences regarding life-sustaining treatments. Despite burdensome symptoms and poor outcomes, limitation of such treatments was rare and occurred late, when patients were near death. Opportunities exist to improve communication and decision-making in chronic critical illness.

[Elective termination of respiratory therapy in amyotrophic lateral sclerosis]

BACKGROUND

Due to the growing use of artificial respiration in amyotrophic lateral sclerosis (ALS), physicians are increasingly confronted with patients seeking discontinuation of therapy. Yet there are few systematic investigations of the withdrawal of ventilation therapy.

PATIENTS AND METHODS

In a retrospective investigation of nine German ALS patients, clinical data were recorded from the discontinuation of noninvasive ventilation (n=4) and mechanical ventilation (n=5).

RESULTS

In cases of residual spontaneous breathing, intensified symptom control of dyspnea and anxiety was possible with intravenous morphine sulfate at a low dose rate (10 mg/h) but high cumulative dose (185-380 mg). The terminal phase after removing the mask was protracted (22:10 h to 28:00 h). In cases of minimal or absent spontaneous breathing the disconnection was realized in deep sedation, which required a moderate total dose of morphine sulfate (120 mg) but a high dosage rate (up to 300 mg/h). The terminal phase in deep sedation was short (15-80 min).

CONCLUSION

The elective termination of ventilation requires differentiated pharmacologic palliative care. More controlled studies are required in order to establish evidence-based guidelines for the termination of ventilation.

Patient involvement in health-related decisions during prolonged critical illness

We describe patterns of communication of patients involved in health-related decision making during prolonged mechanical ventilation (PMV). Data were collected using observation, interview, and record review. Twelve of 30 patients participated in decisions about initiating, withdrawing, and withholding life-sustaining treatment, surgery, artificial feeding, financial/legal issues, discharge care, and daily care procedures. Patient involvement was largely validation or confirmation of what clinicians and families had already decided. Patients' participation was enlisted by clinicians and family members even when the patients did not exhibit full decisional capacity. Patient involvement in health-related decisions during prolonged critical illness is a shared and negotiated process that requires continued empirical study and ethical analysis.

Management guidelines for motor neurone disease patients on non-invasive ventilation at home

Most motor neurone disease (MND) patients die of respiratory system complications. When patients have advanced disease with symptoms of respiratory failure, management issues can become complicated by the introduction of assisted ventilatory devices. Therefore, care provision by a multidisciplinary team must be structured and co-ordinated in order to ensure that patients and their carers receive the optimal level of care. The objective of this article is to review the literature and explore the complex issues surrounding the use of non-invasive positive pressure ventilation (NIPPV) in home care MND patients as a justification for the development of a management guideline for medical practitioners. A guideline for multidisciplinary care of home ventilated MND patients will be proposed.

Interventions to Improve Care during Withdrawal of Life-Sustaining Treatments

Withdrawal of life-sustaining therapies is a common occurrence in the intensive care unit (ICU) setting and also occurs in other hospital settings, long-term care facilities, and even at home. Many studies have documented dramatic geographic variations in the prevalence of withdrawal of life-sustaining therapies, and some evidence suggests this variation may be driven more by physician attitudes and biases than by factors such as patient preferences or cultural differences. A number of studies of interventions in the ICU setting have provided some evidence that withdrawal of life-sustaining therapies is a process of care that can be improved. The interventions have included routine ethics or palliative care consultations, routine family conferences, and standardized order protocol for withdrawal of life support. For some of the interventions, for example, ethics consultations or palliative care consultations, the precise mechanisms by which the process of care is improved are not clear. Furthermore, many of these studies have used surrogate outcomes for quality, such as ICU length of stay. Emerging research suggests more direct outcome measures may be useful, including family satisfaction with care and assessments of the quality of dying. Despite these relative limitations, these studies provide convincing evidence that withdrawal of life-sustaining therapy is a process of care that presents opportunities for quality improvement and that interventions are successful at improving this care. Further research is needed to identify and test the most appropriate and responsive outcome measures and to identify the most effective and cost-effective interventions.

End-of-life decisions during intensive care treatment

PURPOSE OF REVIEW

End-of-life decisions play an important role in the intensive care unit. This review discusses the most important studies on end-of-life decisions published from October 2001 to October 2002.

RECENT FINDINGS

Refusal of admission to the intensive care unit in itself is frequently an end-of-life decision. However, some patients survive rejection. The main end-of-life decisions during intensive care unit stay are withholding or withdrawal of therapy. Some patients have do-not-resuscitate orders on admittance to a unit. The effect of family participation and involvement of other caregivers in such decisions has been extensively studied. Such participation can lead to anxiety and depression in the family. A procedural guideline for decision making is of clinical interest. The background of physicians plays an important role. Terminal sedation and analgesia play an important role in execution of end-of-life decisions. During intensive care unit admission there is a continuous change in circumstances, which causes continuous differences in the wishes of the patients and relatives. The small contribution of the cost of the last days of life to total healthcare cost was reconfirmed.

SUMMARY

The new studies put emphasis on the facts that all care providers should participate in the decision and that communication with surrogates is of extreme importance. Many valid points from other medical fields also apply to the intensive care unit situation.