Palliative Ventilator Withdrawal Practices in an Inpatient Hospice Unit

Abstract

Background

Palliative ventilator withdrawal (PVW) involves removal of mechanical ventilation in patients not expected to survive to allow a peaceful death. This process traditionally occurs in Intensive Care Units (ICU) and recently has evolved to occur in Inpatient Hospice and Palliative Care Units (IPU).

Objectives

To describe the process and response of patients undergoing PVW in an IPU setting.

Methods

This is a longitudinal observational cohort study of adult patients who underwent PVW in an IPU from January 2021 through March 2022.

Results

Among 25 enrolled subjects, median age was 68 (IQR 62.5-76.5) years and 14 (56%) were females. Median time from PVW to death was 16.8 (IQR 2.6-100) hours. A registered nurse and attending physician were present in all the cases, while a respiratory therapist was present in 20 (80%) and chaplain in 9 (36%) of the cases. Before PVW, opioids and benzodiazepines were administered to 24 (96%) patients. Post PVW, respiratory distress was noted among 16 (64%) patients and medication was given to 15 (60%) patients for respiratory distress. There was a significant association between the presence of respiratory distress and administration of medication within 30 minutes after PVW (P = .009). The rituals performed during PVW were reciting prayers for 11 (44%), playing music for 8 (32%), and observing silence for 6 (24%) of the patients.

Conclusion

This study describes the PVW practices in an IPU setting where a multidisciplinary team was present during PVW for most of the cases and two-third of the patients undergoing PVW experienced respiratory distress immediately after PVW.

Keywords

compassionate extubation palliative ventilator withdrawal palliative extubation inpatient hospice unit end of life

Get full access to this article

View all access options for this article.

References

Pham

Brochard

Slutsky

. Mechanical ventilation: State of the Art. Mayo Clin Proc. 2017;92(9):1382-1400. doi:10.1016/j.mayocp.2017.05.004.

O’Mahony

McHenry

Blank

, et al. Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med. 2010;24(2):154-165. doi:10.1177/0269216309346540.

O’Mahony

McHugh

Zallman

Selwyn

. Ventilator withdrawal: procedures and outcomes. Report of a collaboration between a critical care division and a palliative care service. J Pain Symptom Manage. 2003;26(4):954-961. doi:10.1016/s0885-3924(03)00333-6.

Prendergast

Claessens

Luce

. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med. 1998;158(4):1163-1167. doi:10.1164/ajrccm.158.4.9801108.

Cook

Rocker

Marshall

, et al. Withdrawal of mechanical ventilation in anticipation of death in the intensive care Unit. N Engl J Med. 2003;349(12):1123-1132. doi:10.1056/NEJMoa030083.

Daly

Thomas

Dyer

. Procedures used in withdrawal of mechanical ventilation. Am J Crit Care. 1996;5(5):331-338.

Fehnel

Armengol de la Hoz

Celi

, et al. Incidence and risk model Development for severe tachypnea following terminal extubation. Chest. 2020;158(4):1456-1463. doi:10.1016/j.chest.2020.04.027.

Huynh

Walling

Kleerup

Liu

Wenger

. Factors associated with palliative withdrawal of mechanical ventilation and time to death after withdrawal. J Palliat Med. 2013;16(11):1368-1374. doi:10.1089/jpm.2013.0142.

Cooke

Hotchkin

Engelberg

Rubinson

Curtis

. Predictors of time to death after terminal withdrawal of mechanical ventilation in the ICU. Chest. 2010;138(2):289-297. doi:10.1378/chest.10-0289.

10.

Mayer

Kossoff

. Withdrawal of life support in the neurological intensive care unit. Neurology. 1999;52(8):1602-1609. doi:10.1212/wnl.52.8.1602.

11.

Prendergast

Puntillo

. Withdrawal of life support: intensive caring at the end of life. JAMA. 2002;288(21):2732. doi:10.1001/jama.288.21.2732.

12.

Mann

Galler

Williams

Frost

. Caring for patients and families at the end of life: withdrawal of intensive care in the patient’s home. N Z Med J. 2004;117(1196):U935.

13.

Yeow

Chen

. Ventilator withdrawal in anticipation of death: the Simulation Lab as an Educational tool in palliative medicine. J Pain Symptom Manage. 2020;59(1):165-171. doi:10.1016/j.jpainsymman.2019.09.025.

14.

Campbell

Mendez

Yarandi

. An Algorithmic Approach to terminal ventilator withdrawal: Pilot testing (FR416-D). J Pain Symptom Manage. 2015;49(2):362. doi:10.1016/j.jpainsymman.2014.11.094.

15.

Kaur

Syed

Erondu

Stringer

Chen

. Compassionate extubation in adult ICUs: a quality improvement project. Chest. 2020;158(4):A1299. doi:10.1016/j.chest.2020.08.1184.

16.

Binney

Quest

Feingold

Buchman

Majesko

. Feasibility and economic impact of dedicated hospice inpatient units for terminally ill ICU patients. Crit Care Med. 2014;42(5):1074-1080. doi:10.1097/CCM.0000000000000120.

17.

Bodnar

. Terminal withdrawal of mechanical ventilation: a hospice Perspective for the intensivist. J Intensive Care Med. 2019;34(2):156-164. doi:10.1177/0885066618797918.

18.

Yeow

. Your own sweet time: discontinuing ventilator support at home. J Palliat Med. 2015;18(4):388-389. doi:10.1089/jpm.2014.0317.

19.

Laddie

Craig

Brierley

Kelly

Bluebond-Langner

. Withdrawal of ventilatory support outside the intensive care unit: guidance for practice. Arch Dis Child. 2014;99(9):812-816. doi:10.1136/archdischild-2013-305492.

20.

Unger

. Withdrawal of ventilatory support at home on hospice. J Pain Symptom Manage. 2016;52(2):305-312. doi:10.1016/j.jpainsymman.2016.03.004.

21.

Mayer

APT

. Redirection in treatment goals: withdrawal of mechanical ventilation outside of the intensive care unit. Arch Dis Child. 2014;99(9):795-797. doi:10.1136/archdischild-2014-306417.

22.

Long

Muni

Treece

, et al. Time to death after terminal withdrawal of mechanical ventilation: Specific respiratory and Physiologic Parameters may Inform physician predictions. J Palliat Med. 2015;18(12):1040-1047. doi:10.1089/jpm.2015.0115.

23.

Brieva

Coleman

Lacey

Harrigan

Lewin

Carter

. Prediction of death in less than 60 minutes following withdrawal of Cardiorespiratory support in ICUs*. Crit Care Med. 2013;41(12):2677-2687. doi:10.1097/CCM.0b013e3182987f38.

24.

Wind

Snoeijs

MGJ

Brugman

, et al. Prediction of time of death after withdrawal of life-sustaining treatment in potential donors after cardiac death. Crit Care Med. 2012;40(3):766-769. doi:10.1097/CCM.0b013e318232e2e7.

25.

Efstathiou

Vanderspank-Wright

Vandyk

, et al. Terminal withdrawal of mechanical ventilation in adult intensive care units: a systematic review and narrative synthesis of perceptions, experiences and practices. Palliat Med. 2020;34(9):1140-1164. doi:10.1177/0269216320935002.