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

Time to death after compassionate extubation in medical and neuroscience intensive care units

BACKGROUND

Medical ICU (MICU) and neuroscience ICU (NSICU) populations undergoing compassionate extubation (CE) may have different characteristics that affect post-procedure outcomes.

OBJECTIVES

To contrast clinical characteristics and evaluate time to death (TTD) following CE in MICU and NSICU populations.

METHODS

Single-center retrospective cohort study of patients who completed CE in a MICU or NSICU in 2021. Data were obtained by manual chart abstraction. A Mann-Whitney U test was used to compare characteristics between the clinical units.

RESULTS

Fifty patients were included in the study, 27 were in the MICU and 23 in the NSICU. Median age was 68 years. Patients in the MICU had a longer LOS before CE than those in the NSICU (10.0 vs. 3.0 days, p=0.001). Patients in the MICU experienced a shorter median TTD after CE than those in the NSICU (25 vs. 195 mins, p=0.004). MICU patients had a higher pre-hospital burden of illness (median CCI 6 vs 3, p=0.003), and a higher degree of organ failure at CE (median SOFA 12 vs 6, p<0.001), with more severe hypoxemia (PaO2/FiO2 ratio of 149 vs 360, p<0.001). Most MICU patients died of infection or cancer, compared with NSICU patients who had intracranial hemorrhage or ischemic stroke.

CONCLUSION

Patients in the NSICU underwent CE after shorter time in the ICU and survived longer afterwards than MICU patients. Patients in the MICU have a higher pre-hospital severity of illness and a higher level of organ failure at the time of CE compared with NSICU patients.

Attitudes of Patients with Advanced Chronic Illnesses Toward Palliative Extubation in a Country Where It Is Illegal

Background: Palliative extubation (PE) is the cessation of mechanical ventilation (MV) during terminal illness. Although PE is widely practiced in many countries, it remains illegal in others. Attitudes toward PE of patients at the highest risk for MV were scarcely explored before. Objective: To assess the attitudes of patients with advanced chronic illnesses (ACI) toward PE and other end-of-life decisions in a country where PE is illegal. Design: A prospective observational study using questionnaire-based interviews. Setting/Subjects: Patients with ACI hospitalized between 2021 and 2022 in a large tertiary center. Attitudes toward PE and mechanical ventilation were evaluated. Predictors for favoring/opposing PE were analyzed using multivariate logistical regression models. Results: A total of 152 (40% female, 75 ± 11 years) patients were included. The most common ACIs were advanced heart failure (32%), metastatic malignancy (32%), and chronic obstructive pulmonary disease (22%). Around 132 patients (87%) supported the legalization of PE, and their main reason was to avoid pain and suffering (87%). Legalization of PE would change the decision to avoid mechanical intubation in 34% of the cases. Most patients thought that the decision to perform PE should be made by the patient's physician and primary caregiver collaboratively (64%). Religious observance was an independent predictor for opposing PE (adjusted odds ratio 0.18; 95% confidence interval 0.06-0.59; p < 0.01), whereas the type of ACI was not. Conclusion: Most admitted patients with ACIs support the legalization of PE. Such policy change could have major impact on patients' end-of-life preferences. At-risk patients should be the focus of future studies in this area.

Terminal Extubation or Terminal Weaning: Is it Feasible in Indian Intensive Care Units?

Terminal extubation (TE) and weaning have long been suggested as a modality of intervention when the continuation of mechanical ventilation is not expected to achieve its therapeutic aim and is merely prolonging the dying process. The decision, however, is complex considering limited evidence regarding the best practices and is often defied due to inherent ethical, legal, and medical dilemmas. The article attempts a brief overview of available literature on this subject and discusses its feasibility in Indian intensive care units (ICUs).

How to cite this article

Kumar A, Bhat RS, Mani RK. Terminal Extubation or Terminal Weaning: Is it Feasible in Indian Intensive Care Units? Indian J Crit Care Med 2024;28(2):103-105.

Islam

Islam is one of the religions of the book, others being Judaism, Christianity, and Sabianism. It is the second largest religion in the world, the first being Christianity.

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.

Together Till the End: Two Cases of Withdrawal of Life Support

It’s important to consider patients’ wishes regarding treatment options, especially near the end of life to allow patients to die with dignity. Worldwide variability exists regarding the palliative extubation decision, which is performed to relieve suffering by the termination of mechanical ventilation and withdrawal of the breathing tube, consequently avoiding the prolongation of death. It is only performed when it is consistent with patients' values and prognosis. This variability is even more prominent in low-income and developing countries. We are presenting a case report of two patients, a husband and a wife, who underwent palliative extubation and withdrawal of life support on the same day.

Descriptive Analysis of Extubations Performed in an Emergency Department-based Intensive Care Unit

Introduction

Extubation of appropriate patients in the emergency department (ED) may be a strategy to avoid preventable or short-stay intensive care unit (ICU) admissions, and could allow for increased ventilator and ICU bed availability when demand outweighs supply. Extubation is infrequently performed in the ED, and a paucity of outcome data exists. Our objective was to descriptively analyze characteristics and outcomes of patients extubated in an ED-ICU setting.

Methods

We conducted a retrospective observational study at an academic medical center in the United States. Adult ED patients extubated in the ED-ICU from 2015–2019 were retrospectively included and analyzed.

Results

We identified 202 patients extubated in the ED-ICU; 42% were female and median age was 60.86 years. Locations of endotracheal intubation included the ED (68.3%), outside hospital ED (23.8%), and emergency medical services/prehospital (7.9%). Intubations were performed for airway protection (30.2%), esophagogastroduodenoscopy (27.7%), intoxication/ingestion (17.3%), respiratory failure (13.9%), seizure (7.4%), and other (3.5%). The median interval from ED arrival to extubation was 9.0 hours (interquartile range 6.2–13.6). One patient (0.5%) required unplanned re-intubation within 24 hours of extubation. The attending emergency physician (EP) at the time of extubation was not critical care fellowship trained in the majority (55.9%) of cases. Sixty patients (29.7%) were extubated compassionately; 80% of these died in the ED-ICU, 18.3% were admitted to medical-surgical units, and 1.7% were admitted to intensive care. Of the remaining patients extubated in the ED-ICU (n = 142, 70.3%), zero died in the ED-ICU, 61.3% were admitted to medical-surgical units, 9.9% were admitted to intensive care, and 28.2% were discharged home from the ED-ICU.

Conclusion

Select ED patients were safely extubated in an ED-ICU by EPs. Only 7.4% required ICU admission, whereas if ED extubation had not been pursued most or all patients would have required ICU admission. Extubation by EPs of appropriately screened patients may help decrease ICU utilization, including when demand for ventilators or ICU beds is greater than supply. Future research is needed to prospectively study patients appropriate for ED extubation.

Implementing a novel model for hospice and palliative care in the emergency department: An experience from a tertiary medical center in Taiwan

Hospice and palliative care has been recognized as an essential part of emergency medicine; however, there is no consensus on the optimal model for the delivery of hospice and palliative care in the emergency department (ED). Therefore, we conducted a novel implementation in a tertiary medical center in Taiwan. In the preintervention period, we recruited a specialist for hospice and palliative medicine in the ED to lead our intervention. In the early stage of the intervention, starting on July 1, 2014, we encouraged and funded ED physicians and nurses to receive training for hospice and palliative medicine and residents of emergency medicine to rotate to the hospice ward. In the late stage of the intervention, we initiated educational programs in the ED, an interdisciplinary meeting with the hospice team every month, sharing information and experience via a cell phone communication app, and setting aside an emergency hospice room for end-of-life patients. We compared the outcomes among pre-, during, and postintervention periods. Compared with 4 in the preintervention period, the cases of do not resuscitate (DNR) per month increased significantly to 30.1 in the early stage of intervention, 23.9 in late stage of intervention, and 34.6 in the postintervention period (all P < .001 compared with the preintervention period). Compared with 10.8% in the preintervention period, the ratio of DNR orders signed in the ED/total DNR orders signed in the study hospital was increased to 17.1% in early stage of intervention, 12.5% in late stage of intervention, and 22.8% in postintervention. Compared with zero in preintervention and early intervention, the cases of consultation with the hospice team increased significantly to 19 cases per month in the late stage of intervention and postintervention. The ability of nurses in hospice and palliative care, including knowledge and the timing and method of consultation with the hospice team, was also significantly improved. We successfully implemented a novel model of hospice and palliative care in the ED via a champion, education, and close collaboration with the hospice team, which could be an important reference for other EDs and intensive care unit in the future.