There is a concern that as a result of COVID-19 there will be a shortage of ventilators for patients requiring respiratory support. This concern has resulted in significant debate about whether it is appropriate to withdraw ventilation from one patient in order to provide it to another patient who may benefit more. The current advice available to doctors appears to be inconsistent, with some suggesting withdrawal of treatment is more serious than withholding, while others suggest that this distinction should not be made. We argue that there is no ethically relevant difference between withdrawing and withholding treatment and that suggesting otherwise may have problematic consequences. If doctors are discouraged from withdrawing treatment, concern about a future shortage may make them reluctant to provide ventilation to patients who are unlikely to have a successful outcome. This may result in underutilisation of available resources. A national policy is urgently required to provide doctors with guidance about how patients should be prioritised to ensure the maximum benefit is derived from limited resources.
Background: Patients requiring mechanical ventilation (MV) have high morbidity and mortality. Providing palliative care has been suggested as a way to improve comprehensive management. The objective of this retrospective cross-sectional study was to identify predictors for palliative care utilization and the association with hospital length of stay (LOS) among surgical patients requiring prolonged MV (= 96 consecutive hours).
Methods: National Inpatient Sample (NIS) data 2009–2013 was used to identify adults (age = 18) who had a surgical procedure and required prolonged MV (= 96 consecutive hours), as well as patients who also had a palliative care encounter. Outcomes were palliative care utilization and association with hospital LOS.
Results: Utilization of palliative care among surgical patients with prolonged MV increased yearly, from 5.7% in 2009 to 11.0% in 2013 (p < 0.001). For prolonged MV surgical patients who died, palliative care increased from 15.8% in 2009 to 33.2% in 2013 (p < 0.001). Median hospital LOS for patients with and without palliative care was 16 and 18 days, respectively (p < 0.001). Patients discharged to either short or long term care facilities had a shorter LOS if palliative care was provided (20 vs. 24 days, p < 0.001). Factors associated with palliative care utilization included older age, malignancy, and teaching hospitals. Non-Caucasian race was associated with less palliative care utilization.
Conclusions: Among surgical patients receiving prolonged MV, palliative care utilization is increasing, although it remains low. Palliative care is associated with shorter hospital LOS for patients discharged to short or long term care facilities.
The global pandemic of coronavirus disease 2019 (COVID-19) is placing significant strain on health-care resources worldwide Although most patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) do not require hospital admission, severe illness commonly leads to acute respiratory distress syndrome necessitating invasive mechanical ventilation. Unfortunately, ventilator scarcity has become a bottleneck in the provision of care to critically ill patients with COVID-19.
Previously-stated DNR status would seem irrelevant to ventilator allocation, and yet some existing and proposed guidelines for triage during a public health emergency list DNR status in the list of criteria for excluding patients from getting ventilators or other life-saving health care. This approach is in direct opposition to the generally agreed-upon goal of maximizing the number of survivors, and could result in confusion and public mistrust of the health care system.
Physicians in the intensive care unit (ICU), in charge of patients with severe acute respiratory distress syndrome (ARDS) due to Coronavirus (SARS-CoV-2), face a difficult dilemma: to improve gas exchange, oxygen transport and tissue oxygenation using mechanical ventilation (MV), or to limit ventilator-induced lung injury (VILI) associated with prolonged MV. In addition, while MV often requires deep sedation with or without neuromuscular blocking agents (NMBA) to tolerate MV and limit the risk of VILI, deep and/or prolonged sedation is associated with several complications, e.g. delirium, withdrawal syndromes, propofol -related infusion syndrome (PRIS), haemodynamic instability, ICU acquired muscle weakness, and difficult MV weaning leading to a sustained utilisation of ICU resources, As the Coronavirus pandemic is associated with a shortage of sedatives and NMBA drugs in several countries including France, it is critical to discuss the role of sedation in this particular context.
Background: The coronavirus disease 2019 pandemic has or threatens to overwhelm health care systems. Many institutions are developing ventilator triage policies.
Objective: To characterize the development of ventilator triage policies and compare policy content.
Design: survey and mixed-methods content analysis.
Setting: North American hospitals associated with members of the Association of Bioethics Program Directors.
Participants: Program directors.
Measurements: Characteristics of institutions and policies, including triage criteria and triage committee membership.
Results: sixty-seven program directors responded (response rate, 91.8%); 36 (53.7%) hospitals did not yet have a policy, and 7 (10.4%) hospitals' policies could not be shared. The 29 institutions providing policies were relatively evenly distributed among the 4 U.S. geographic regions (range, 5 to 9 policies per region). Among the 26 unique policies analyzed, 3 (11.3%) were produced by state health departments. The most frequently cited triage criteria were benefit (25 policies [96.2%]), need (14 [53.8%]), age (13 [50.0%]), conservation of resources (10 [38.5%]), and lottery (9 [34.6%]). Twenty-one (80.8%) policies use scoring systems, and 20 of these (95.2%) use a version of the Sequential Organ Failure Assessment score. Among the policies that specify the triage team's composition (23 [88.5%]), all require or recommend a physician member, 20 (87.0%) a nurse, 16 (69.6%) an ethicist, 8 (34.8%) a chaplain, and 8 (34.8%) a respiratory therapist. Thirteen (50.0% of all policies) require or recommend those making triage decisions not be involved in direct patient care, but only 2 (7.7%) require that their decisions be blinded to ethically irrelevant considerations.
Limitation: the results may not be generalizable to institutions without academic bioethics programs.
Conclusion: Over one half of respondents did not have ventilator triage policies. Policies have substantial heterogeneity, and many omit guidance on fair implementation.
Background: The probability of weaning and of long-term survival of chronically mechanically ventilated cancer patients is unknown, with incomplete information available to guide therapeutic decisions. We sought to determine the probability of weaning and overall survival of cancer patients requiring long-term mechanical ventilation in a specialized weaning unit.
Methods: A single-institution retrospective review of patients requiring mechanical ventilation outside of a critical care setting from 2008 to 2012 and from January 1 to December 31, 2018, was performed. Demographic and clinical data were recorded, including cancer specifics, comorbidities, treatments, and outcomes. Overall survival was determined using the Kaplan-Meier approach. Time to weaning was analyzed using the cumulative incidence function, with death considered a competing risk. Prognostic factors were evaluated for use in prospective evaluations of weaning protocols.
Results: between 2008 and 2012, 122 patients required mechanical ventilation outside of a critical care setting with weaning as a goal of care. The cumulative incidence of weaning after discharge from the intensive care unit was 42% at 21 days, 49% at 30 days, 58% at 60 days, 61% at 90 days, and 61% at 120 days. The median survival was 0.16 years (95% CI, 0.12 to 0.33) for those not weaned and 1.05 years (95% CI, 0.60 to 1.34) for those weaned. Overall survival at 1 year and 2 years was 52 and 32% among those weaned and 16 and 9% among those not weaned. During 2018, 36 patients at our institution required mechanical ventilation outside of a critical care setting, with weaning as a goal of care. Overall, with a median follow-up of 140 days (range, 0–425 days; average, 141 days), 25% of patients requiring long-term mechanical ventilation (9 of 36) are alive.
Conclusions: Cancer patients can be weaned from long-term mechanical ventilation, even after prolonged periods of support. Implementation of a resource-intensive weaning program did not improve rates of successful weaning. No clear time on mechanical ventilation could be identified beyond which weaning was unprecedented. Short-term overall survival for these patients is poor.
As the coronavirus disease 2019 (COVID-19) pandemic intensifies, shortages of ventilators have occurred in Italy and are likely imminent in parts of the US. In ordinary clinical circumstances, all patients in need of
mechanical ventilation because of potentially-reversible conditions receive it, unless they or their surrogates decline. However, there are mounting concerns in many countries that this will not be possible and that patients
who otherwise would likely survive if they received ventilator support will die because no ventilator is available. In this type of public health emergency, the ethical obligation of physicians to prioritize the well-being of individual
patients may be overridden by public health policies that prioritize doing the greatest good for the greatest number of patients.These circumstances raise a critical question: when demand for ventilators and other intensive
treatments far outstrips the supply, what criteria should guide these rationing decisions?
The Covid-19 pandemic has led to severe shortages of many essential goods and services, from hand sanitizers and N-95 masks to ICU beds and ventilators. Although rationing is not unprecedented, never before has the American public been faced with the prospect of having to ration medical goods and services on this scale.
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OBJECTIVE: The aim of this study was to explore the status of aggressive end-of-life care and symptom relief treatments in terminally ill patients who had discussed the withdrawal of mechanical ventilation.
METHODS: This research is a retrospective observational study based on a chart review. Terminal patients aged = 20 years, who were intubated with mechanical ventilation support, who underwent hospice-shared care, and who personally, or whose close relatives, had discussed the withdrawal of mechanical ventilation with hospice-shared care team members in a tertiary hospital in Taiwan during 2012 to 2015 were included. Demographics, medical conditions, and aggressive end-of-life care, including hospitalization, use of vasopressors, artificial nutrition, tube feeding, antibiotics, and symptom relief treatments including the use of opioids, steroids, and sedatives, were identified. The modes of care and treatments of patients by the status of withdrawal of mechanical ventilation were compared.
RESULTS: A total of 141 patients had discussed the withdrawal of mechanical ventilation, and 111 (78.7%) had been withdrawn. Aggressive end-of-life care was noted in all patients regardless of mechanical ventilation status. There were no significant differences in the number and pattern of aggressive end-of-life care measures between patients who had or had not been withdrawn. There were significantly higher rates of symptom relief treatments used in patients who had been withdrawn.
CONCLUSIONS: Aggressive end-of-life care is common for patients who have discussed the withdrawal of mechanical ventilation. There are significantly higher rates of symptom relief medications administered in patients who have been withdrawn from mechanical ventilation.
AIMS AND OBJECTIVES: This study explores everyday life experience of relatives of people with ALS living at home with mechanical ventilation and formal caregivers.
BACKGROUND: ALS is a rapidly progressive disease affecting not only the patient but also close relatives. A burden is placed on relatives affecting their mental and physical health in settings where they provide care. Few studies have examined the everyday life challenges of close relatives with formal caregivers at home and home mechanical ventilation, which often prolongs survival.
DESIGN: We undertook a qualitative study with a phenomenological-hermeneutic approach inspired by Ricoeur. Eleven close relatives were interviewed and the three-level analysis method developed by Dreyer and Pedersen was conducted. The Consolidated Criteria for Reporting Qualitative Research checklist was used.
RESULTS: Four themes were derived from the data during analysis: Vulnerable relatives fighting to keep track of everything, Formal caregivers - a distressing relief, A prison without personal space, and We are in this together until the end.
CONCLUSIONS: Close relatives of persons with ALS are burdened with everyday life challenges despite having formal caregivers at home, and they feel imprisoned. Despite these challenges and concerns about the end of life of their relative, they stay until the end.
RELEVANCE TO CLINICAL PRACTICE: There is clearly a need to investigate interventions in clinical practice supporting close relatives to prepare them for what to expect during a prolonged disease course.
Elderly patients suffering from chronic cardio-pulmonary diseases commonly experience acute respiratory failure. As in younger patients, a well-known therapeutic approach of noninvasive mechanical ventilation is able to prevent orotracheal intubation in a large number of severe scenarios in elderly patients. In addition, this type of ventilation is frequently applied in elderly patients who refuse intubation for invasive mechanical ventilation. The rate of failure of noninvasive ventilation may be reduced by means of the integration of new technological devices (i.e., high-flow nasal cannula, extracorporeal CO2 removal, cough assistance and high-frequency chest wall oscillation, and fiberoptic bronchoscopy). Ethical issues with end-of-life decisions and the choice of the environment are not clearly defined in the treatment of elderly with acute respiratory insufficiency.
INTRODUCTION: Multiple organ failure has been considered a contraindication for noninvasive ventilation (NIV).
MATERIALS AND METHODS: We described the outcome of Do-not-Intubate (DNI) patients with acute respiratory failure, treated with NIV and, subsequently, necessitating renal replacement therapy (RRT).
RESULTS AND DISCUSSION: Seven patients admitted to our Respiratory Intensive Care Unit, developed Acute Kidney Injury (AKI) during NIV treatment and received RRT for 12.8 ± 8 days together with NIV. All the patients but one, discontinued renal support because they regained a satisfactory urinary output; nevertheless mortality rate was high (71%).
CONCLUSION: Our data suggest that RRT could be feasible together with NIV. RRT was associated with an acute improvement in renal function but did not modify the mortality rate.
BACKGROUND: We sought to evaluate the effect of an integrated prospective payment program (IPP) on knowledge of hospice care and willingness to participate in hospice care among family members of patients on prolonged mechanical ventilation (PMV).
METHODS: Between November 2013 and April 2014, we used paper-based survey questionnaires from 64 institutions to evaluate knowledge, willingness, and related factors among the main caregivers of patients on PMV regarding hospice care and to determine whether their decisions for the patients were affected by the IPP.
RESULTS: The average ages of the respondents and patients on PMV were 51.9 y and 70.8 y respectively; 70.6% of the respondents knew about the Hospice Palliative Care Act (HPCA), and 42.3% of the medical staff had introduced hospice care-related information to patients and caregivers in Taiwan. Among the caregiver respondents, 67.6% agreed to write a letter of intent regarding the choice of hospice care or limited life-sustaining treatment. In total, 66.2% (16.1 + 50.1%) of the respondents agreed to hospice care for their family members (ie, the patients on PMV) when the condition was terminal. The factors of greater HPCA knowledge among the patients on PMV were IPP participation, female sex, and coma status. Factors leading to higher levels of HPCA knowledge included age = 65 y being married, higher income, awareness of the law, and being introduced to hospice care by medical staff.
CONCLUSIONS: High levels of hospice care knowledge were unrelated to willingness to participate. HPCA knowledge was greater in the IPP group than in the non-IPP group; however, there was no significant difference in the willingness to agree to hospice care. It is recommended that individuals be encouraged to express their medical decisions.
Purpose: Nonbenzodiazepines are preferred for continuous sedation in mechanically ventilated intensive care unit (ICU) patients. Although dexmedetomidine and propofol have blood pressure lowering properties, limited data exist about the hemodynamic effects of concomitant administration. The purpose of this study was to compare the adverse hemodynamic event rate with concomitant dexmedetomidine and propofol compared to either agent alone in mechanically ventilated ICU patients.
Methods: This retrospective cohort study was conducted at a university medical center. Adult ICU patients (=18 years) admitted between October 20, 2015, and January 25, 2018, and administered concurrent dexmedetomidine and propofol or either agent alone for =24 hours were included. Mean arterial pressure, heart rate, and sedative dosing requirements were assessed from initiation to 72 hours after initiation. The primary end point was comparing the incidence of hypotension among study groups. Secondary aims compared the incidence of tachycardia and bradycardia as well as clinical outcomes.
Results: Overall, 276 patients were included among combination (n = 93), dexmedetomidine (n = 91), and propofol (n = 92) groups. The incidence of hypotension was significantly higher in patients administered concomitant dexmedetomidine and propofol (62.4%) compared to those administered dexmedetomidine (23.1%) or propofol (23.9%) alone (P < .0001). Adjunctive dexmedetomidine with propofol was also associated with higher rates of clinically relevant hypotension requiring treatment (P = .048). The tachycardia incidence in the concomitant, dexmedetomidine, and propofol groups were 30.1%, 28.6%, and 14.1%, respectively (P = 02). Only 1.4% (n = 4) of all study patients developed bradycardia. Concomitant therapy was an independent risk factor of hypotension compared to either dexmedetomidine (odds ratio [OR]: 6.7, 95% confidence interval [CI]: 2.61-17.3, P < .0001) or propofol (OR: 2.89, 95% CI: 1.24-6.74, P = .014) monotherapy. Patients experiencing hypotension were associated with worse clinical outcomes.
Conclusion: Concomitant dexmedetomidine and propofol use in mechanically ventilated patients increased the risk of hypotensive events. Adjunctive dexmedetomidine with propofol administration in the critically ill warrants caution.
Simulation is a growing model of education in many medical disciplines. Withdrawal of mechanical ventilation is an important skillset for palliative medicine practitioners who must be facile with a variety of end-of-life scenarios and is well suited to the simulation laboratory. We describe a novel approach using high fidelity simulation to design a curriculum to teach Hospice & Palliative Medicine (HPM) fellows the practical aspects of managing a compassionate terminal extubation. This simulation session aims to equip palliative fellows with a knowledge base of respiratory physiology and mechanical ventilation as well as the practical experience of performing a terminal extubation. We designed a 3 hour simulation session which includes a one hour didactic followed by 2 hours of simulation, with 4 cases that focus on different teaching points regarding symptom management and practical aspects of removing the endotracheal tube . The session was designed as an annual session for HPM fellows in our region during a collaborative educational conference. Based on feedback, the session is scheduled for the beginning of the academic year and each fellow is given the opportunity to physically remove the endotracheal tube. Simulation can be effectively used to teach practical and complex bedside skills such as withdrawal of mechanical ventilation to palliative medicine trainees. This method of teaching could be expanded to teach other advanced hospice and palliative care skills.
PURPOSE OF REVIEW: The purpose of this review is the 'when' and 'how' of the matter of withdrawing noninvasive ventilation (NIV) at end-of-life (EoL) setting, having in mind the implications for patients, families and healthcare team.
RECENT FINDINGS: Several recent publications raised the place and potential applications of NIV at EoL setting. However, there are no clear guidelines about when and how to withdraw NIV in these patients. Continuing NIV in a failing clinical condition may unnecessarily prolong the dying process. This is particularly relevant as frequently, EoL discussions are started only when patients are in severe distress, and they have little time to discuss their preferences and decisions.
SUMMARY: Better advanced chronic disease and EoL condition definitions, as well as identification of possible scenarios, should help to decision-making and find the appropriate time to initiate, withhold and withdraw NIV. This review emphasized the relevance of an integrated approach across illness' trajectories and key transitions of patients who will need EoL care and such sustaining support measure.
INTRODUCTION: Positive pressure ventilation (PPV) with T-Piece and self-inflating bag (SIB) during neonatal resuscitation after birth is associated with variability in ventilation. The use of a ventilator with respiratory function monitoring (RFM) for PPV, however, has not been evaluated.
OBJECTIVE: To determine if ventilator + RFM can reduce ventilation variability compared to T-Piece and SIB in a preterm manikin at different combinations of target tidal volume (VT) and lung compliance (CL).
METHODS: Twenty clinicians provided PPV via mask and endotracheal tube (ETT) using SIB, T-Piece, T-Piece + RFM and Ventilator + RFM to a manikin with adjustable lung CL. Three combinations of CL and target VT: Low CL-Low VT, Low CL-High VT and High CL-Low VT were used in a random order.
RESULTS: The use of ventilator + RFM for PPV via ETT during High CL-Low VT period reduced the proportion of breaths with expiratory VT above target when compared to the other 3 devices (56 ± 35%, 85 ± 20%, 90 ± 25%, 92 ± 12% for ventilator + RFM, T-Piece + RFM, T-Piece, SIB, respectively; p < 0.05). During PPV via both mask and ETT, ventilator + RFM maintained the set Ti and rate, whereas SIB and T-Piece use resulted in higher rates, and T-Piece in higher proportion of breaths with prolonged Ti. During PPV via mask, ventilator + RFM reduced gas leakage compared to other devices.
CONCLUSION: In this simulation study, use of a mechanical ventilator with RFM led to an overall improvement in volume targeting at different settings of CL and reduced the gas leak during mask ventilation. The efficacy and safety of using this strategy to neonatal resuscitation in the delivery room needs to be evaluated.