Respiratory Therapists' Experiences and Attitudes Regarding Terminal Extubations and End-of-Life Care

Health Care Professionals' Perceptions of Extubation During Withdrawal of Therapy in the Intensive Care Unit

Background: Withdrawal of life-sustaining therapy can include the decision to extubate as part of end-of-life practices in the intensive care unit (ICU). Objectives: The purpose of this study was to explore ICU health care professionals (HCPs) perceptions regarding this procedure. Design: An online questionnaire was used to gather data on ICU HCPs' experiences and views regarding extubation. Setting/Subjects: This single-centered study was conducted in Switzerland from January 15 to March 15, 2019, and included physicians, nurses, and nurse assistants. Measurements: The survey assessed HCPs' emotional and ethical responses to extubation, perceptions of patient suffering, and the management of death rattles (DR). Results: A total of 150 out of 227 invited (66%) ICU HCPs participated in the study. Extubation was negatively experienced by 65 (44%) professionals. Twenty-two HCPs (15%) perceived the procedure as violent, while 12 (8%) considered it to be equivalent to suffocation. Eleven respondents (7%) considered it as active euthanasia. Five nurses (21%) and 14 nurse assistants (14%) perceived DR as an indication of patient suffering. Eighty-nine HCPs (95%) wished to treat DR for family's comfort, while 60 (64%) desired to care for it to alleviate their discomfort. The primary source of discomfort arose from the lack of know-how (n = 122, 82%), patient comfort (n = 114, 79%), and symbols of life's impermanence (n = 76, 51%). Beliefs about family distress and patient suffering positively influenced the decision to treat DR. Conclusions: While extubation in the context of end-of-life practices might be ethically sound, HCPs differed in their views on the potential suffering and DR that might be induced by this practice. HCPs discomfort was associated with difficulties in assessing patient comfort, family distress, and lack of know-how.

Health Care Professionals' Views and Practices Regarding Bereavement Support

BACKGROUND

Because the death of a loved one is distressing for families, bereavement support is recommended for high-quality end-of-life care. Although health care professionals provide support during the death, many do not routinely follow up with bereaved families.

OBJECTIVES

To describe and compare how health care professionals view and provide bereavement support.

METHODS

This prospective, cross-sectional study assessed registered nurses, physicians, social workers, respiratory therapists, and unlicensed assistive personnel working in the intensive care unit, step-down unit, and emergency department. Health care professionals completed a survey assessing their views, practices, and training in providing bereavement support to families. Descriptive statistics and the Kruskal-Wallis test were used to describe and compare the groups.

RESULTS

Among 123 health care professionals, 67.5% were registered nurses and 78% were female. Most (64.2%) supported families at the time of death; however, only 6.5% followed up with bereaved families in the weeks after the death. Physicians, social workers, and registered nurses provided bereavement support more often than unlicensed assistive personnel and respiratory therapists did (P = .001). Only 29.3% were very comfortable providing support to bereaved families. Respiratory therapists were less comfortable than other health care professionals (P = .002). Most health care professionals (54.5%) wanted formal training on providing bereavement support. The main barriers to providing bereavement support included lack of training, time, and resources.

CONCLUSIONS

Understanding health care professionals' views and practices on providing bereavement support may help inform the development of appropriate educational materials, interventions, and protocols around bereavement support.

Palliative Extubation: A Discussion of Practices and Considerations

Palliative extubation (PE), also known as compassionate extubation, is a common event in the critical care setting and an important aspect of end-of-life care.1 In a PE, mechanical ventilation is discontinued. Its goal is to honor the patient's preferences, optimize comfort, and allow a natural death when medical interventions, including maintenance of ventilatory support, are not achieving desired outcomes. If not done effectively, PE can cause unintended physical, emotional, psychosocial, or other stress for patients, families, and healthcare staff. Studies show that PE is done with much variability across the globe, and there is limited evidence of best practice. Nevertheless, the practice of PE increased during the coronavirus disease 2019 pandemic due to the surge of dying mechanically ventilated patients. Thus, the importance of effectively conducting a PE has never been more crucial. Some studies have provided guidelines for the process of PE. However, our goal is to provide a comprehensive review of issues to consider before, during, and after a PE. This paper highlights the core palliative skills of communication, planning, symptom assessment and management, and debriefing. Our aim is to better prepare healthcare workers to provide quality palliative care during PEs, most especially when facing future pandemics.

Dilemas bioéticos experimentados por el cuidador respiratorio durante el retiro de la ventilación mecánica en adultos al final de la vida

Introducción: sobre el retiro de la ventilación mecánica al final de la vida, la literatura ha documentado brechas conceptuales en los cuidadores respiratorios y los consecuentes dilemas bioéticos a los que se enfrentan estos profesionales. Objetivo: analizar los dilemas bioéticos que experimentan los cuidadores respiratorios durante el retiro de la ventilación mecánica en adultos al final de la vida a partir de una revisión integradora de la literatura publicada entre 2010 y 2021. Metodología: revisión integrativa de la literatura siguiendo los lineamientos de Whittemore & Knafl (2005) y Guirao Goris (2015). Para el análisis de la información se realizó una evaluación crítica de la literatura acopiada para identificar patrones de comportamiento de los cuidadores respiratorios. Resultados: las enfermedades no transmisibles y crónicas fueron identificadas como las principales condiciones clínicas que determinan la toma de decisiones del cuidador respiratorio en el retiro de la ventilación mecánica paliativa; prolongar la vida de forma artificial a pacientes en estado terminal fue el dilema bioético más frecuente. Conclusiones: los profesionales del cuidado respiratorio enfrentan dilemas éticos en el retiro de la ventilación mecánica al final de la vida de pacientes con afecciones oncológicas y no oncológica; la toma de decisiones se realiza principalmente con base en los principios bioéticos clásicos de Respeto por la autonomía, Beneficencia, No maleficencia y Justicia. Se evidencia la carencia de estudios sobre bioética en diálogo con lineamientos de la Declaración Universal sobre Bioética y Derechos humanos.

Terminal withdrawal of mechanical ventilation in adult intensive care units: A systematic review and narrative synthesis of perceptions, experiences and practices

BACKGROUND

During the terminal withdrawal of life-sustaining measures for intensive care patients, the removal of respiratory support remains an ambiguous practice. Globally, perceptions and experiences of best practice vary due to the limited evidence in this area.

AIM

To identify, appraise and synthesise the latest evidence around terminal withdrawal of mechanical ventilation in adult intensive care units specific to perceptions, experiences and practices.

DESIGN

Mixed methods systematic review and narrative synthesis. A review protocol was registered on PROSPERO (CRD42018086495).

DATA SOURCES

Four electronic databases were systematically searched (Medline, Embase, CENTRAL and CINAHL). Obtained articles published between January 2008 and January 2020 were screened for eligibility. All included papers were appraised using relevant appraisal tools.

RESULTS

Twenty-five papers were included in the review. Findings from the included papers were synthesised into four themes: 'clinicians' perceptions and practices'; 'time to death and predictors'; 'analgesia and sedation practices'; 'physiological and psychological impact'.

CONCLUSIONS

Perceptions, experiences and practices of terminal withdrawal of mechanical ventilation vary significantly across the globe. Current knowledge highlights that the time to death after withdrawal of mechanical ventilation is very short. Predictors for shorter duration could be considered by clinicians and guide the choice of pharmacological interventions to address distressing symptoms that patients may experience. Clinicians ought to prepare patients, families and relatives for the withdrawal process and the expected progression and provide them with immediate and long-term support following withdrawal. Further research is needed to improve current evidence and better inform practice guidelines.