The Lived Experience of Respiratory Therapists During Withdrawal of Advanced Life-Sustaining Therapies at End of Life in the ICU

BACKGROUND

The act of withdrawing advanced life-sustaining therapies, more specifically mechanical ventilation, is performed in hospitals all over the world. Success involves coordination of several members of the patient care team, including nurses, providers (physicians nurse practitioners, or physician assistants), and respiratory therapists (RTs). The experiences of RTs surrounding this procedure are not well documented. The aim of this study was to explore the lived experience of RTs who have participated in withdrawal of advanced life-sustaining therapies, utilizing a hermeneutical phenomenological approach.

METHODS

Individual interviews were conducted with experienced RTs that were audio recorded and transcribed. The data were analyzed by 4 health professionals, and data were triangulated.

RESULTS

Three themes emerged from the study: (1) impact of power relations surrounding the process, (2) needing tools to provide quality withdrawal of advanced life-sustaining therapies, and (3) emotional involvement/exposure. It was clear from the analysis that RTs desire more education, to be part of the decision-making, and to be appreciated for their role in this emotional process.

CONCLUSIONS

Through this study, the role of RT in withdrawal of advanced life-sustaining therapies is better understood, which can only lead to improvement in the overall process for health care team, patient, and families.

Compassionate extubation for a peaceful death in the setting of a community hospital: a case-series study

BACKGROUND

The use of compassionate extubation (CE) to alleviate suffering by terminating mechanical ventilation and withdrawing the endotracheal tube requires professional adherence and efficiency. The Hospice Palliative Care Act, amended on January 9, 2013, legalizes the CE procedure in Taiwan.

METHODS

From September 20, 2013 to September 2, 2014, the hospice palliative care team at a community hospital received 20 consultations for CE. Eight cases were excluded because of non-qualification. Following approval from the Ethics Committee, the medical records of the remaining 12 patients were reviewed and grouped by the underlying disease: A, "terminal-stage cancer"; B, "non-cancer out-of-hospital cardiac arrest"; and C, "non-cancer organ failure". Time to extubation using a cut-off at 48 hours was assessed.

RESULTS

The mean ages of patients (standard deviation) in groups A, B, and C were 66.3 (14.9) years, 72 (19.1) years, and 80.3 (4.0) years, respectively. The mean number of days of intubation at consultation were 6.8 (4.9), 7.3 (4.9), and 179.3 (271.6), respectively. The mean total doses of opioids (as morphine-equivalent dose) in the 24 hours preceding CE were 76 (87.5) mg, 3.3 (5.8) mg, and 43.3 (15.3) mg. The median times from extubation (range) to death were 97 (0.2-245) hours, 0.3 (0.2-0.4) hours, and 6.1 (3.6-71.8) hours. Compared to those requiring <48-hour preparatory time, patients requiring >48 hours to the moment of CE were younger (62.8 years vs 75.5 years), required a mean time of 122 hours (vs 30 hours) to CE (P=0.004), had shorter length of stay (33.3 days vs 77.8 days), required specialist social worker intervention in 75% of cases (vs 37.5%), and had a median duration of intubation of 11.5 days (vs 5.5 days).

CONCLUSION

CE was carried out according to protocol, and the median time from extubation to death varies determined by the underlying disease which was 0.3 hour in patients admitted after out-of-hospital cardiac arrest and 97 hours in patients with advanced cancer.