Compassionate Removal of Heated High-Flow Nasal Cannula for End of Life: Case Series and Protocol Development.

Patients often receive burdensome care at the end of life in the form of interventions that may need to be removed. Heated high-flow oxygen delivered through a nasal cannula (HHFNC) is one such intervention that can be delivered in the hospital yet is rarely available outside of this setting. During the COVID-19 (coronavirus disease 2019) pandemic, health care systems continue to face the possibility of rationing critical life-sustaining equipment that may include HHFNC. We present a clinical protocol designed for weaning HHFNC to allow a natural death and ensuring adequate symptom management throughout the process. This was a retrospective chart review of 8 patients seen by an inpatient palliative care service of an academic tertiary referral hospital who underwent terminal weaning of HHFNC using a structured protocol to manage dyspnea. Eight patients with diverse medical diagnoses, including COVID-19 pneumonia, underwent terminal weaning of HHFNC according to the clinical protocol with 4 down-titrations of approximately 25% for both fraction of inspired oxygen and liter flow with preemptive boluses of opioid and benzodiazepine. Clinical documentation supported good symptom control throughout the weaning process. This case series provides preliminary evidence that the clinical protocol proposed has the ability to ensure comfort through terminal weaning of HHFNC.

A pilot survey of ventilated cancer patients' perspectives and recollections of early mobility in the intensive care unit.

PURPOSE: To determine the level of recall, satisfaction, and perceived benefits of early mobility (EM) among ventilated cancer patients after extubation in the intensive care unit (ICU). METHODS: A survey of patients' perceptions and recollections of EM was administered within 72 h of extubation. Data on recall of EM participation, activities achieved, adequacy of staffing and rest periods, strength to participate, activity level of difficulty, satisfaction with staff instructions, breathing management, and overall rating of the experience were analyzed. The Confusion Assessment Method for ICU (CAM-ICU) was used for delirium screening. RESULTS: Fifty-four patients comprised the study group. Nearly 90% reported satisfaction with instructions, staffing, rest periods, and breathing management during EM. Participants indicated that EM maintained their strength (67%) and gave them control over their recovery (61%); a minority felt optimistic (37%) and safe (22%). Patients who achieved more sessions and "out-of-bed" exercises had better recall of actual activities compared with those who exercised in bed. Overall, patients with CAM-ICU-positive results (33%) performed less physical and occupational therapy exercises. CONCLUSIONS: Ventilated cancer patients reported an overall positive EM experience, but factual memory impairment of EM activities was common. These findings highlight the needs and the importance of shaping strategies to deliver a more patient focused EM experience.

Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study).

PURPOSE: The relative merits of immediate extubation versus terminal weaning for mechanical ventilation withdrawal are controversial, particularly regarding the experience of patients and relatives. METHODS: This prospective observational multicentre study (ARREVE) was done in 43 French ICUs to compare terminal weaning and immediate extubation, as chosen by the ICU team. Terminal weaning was a gradual decrease in the amount of ventilatory assistance and immediate extubation was extubation without any previous decrease in ventilatory assistance. The primary outcome was posttraumatic stress symptoms (Impact of Event Scale Revised, IES-R) in relatives 3 months after the death. Secondary outcomes were complicated grief, anxiety, and depression symptoms in relatives; comfort of patients during the dying process; and job strain in staff. RESULTS: We enrolled 212 (85.5%) relatives of 248 patients with terminal weaning and 190 relatives (90.5%) of 210 patients with immediate extubation. Immediate extubation was associated with airway obstruction and a higher mean Behavioural Pain Scale score compared to terminal weaning. In relatives, IES-R scores after 3 months were not significantly different between groups (31.9 ± 18.1 versus 30.5 ± 16.2, respectively; adjusted difference, -1.9; 95% confidence interval, -5.9 to 2.1; p = 0.36); neither were there any differences in complicated grief, anxiety, or depression scores. Assistant nurses had lower job strain scores in the immediate extubation group. CONCLUSIONS: Compared to terminal weaning, immediate extubation was not associated with differences in psychological welfare of relatives when each method constituted standard practice in the ICU where it was applied. Patients had more airway obstruction and gasps with immediate extubation. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01818895.

Anesthesia management by residents does not alter the incidence of recall of tracheal extubation: a teaching hospital-based propensity score analysis / A administração de anestesia por residentes não altera a incidência de memória da extubação traqueal: uma análise de pontuação de propensão baseada no ensino hospitalar

Abstract Background and objectives: The memory of emergence from anesthesia is recognized as one type of anesthesia awareness. Apart from planed awake extubation, unintentional recall of tracheal extubation is thought to be the results of inadequate anesthesia management; therefore, the incidence can be related with the experience of anesthetists. To assess whether the incidence of recall of tracheal extubation is related to anesthetists' experience, we compared the incidence of recall of tracheal extubation between patients managed by anesthesia residents or by experienced anesthetists. Methods: This is a retrospective review of an institutional registry containing 21,606 general anesthesia cases and was conducted with the board of ethical review approval. All resident tracheal extubations were performed under anesthetists' supervision. To avoid channeling bias, propensity score analysis was used to generate a set of matched cases (resident managements) and controls (anesthetist managements), yielding 3,475 matched patient pairs. The incidence of recall of tracheal extubation was compared as primary outcomes. Results: In the unmatched population, there was no difference in the incidences of recall of tracheal extubation between resident management and anesthetist management (6.5% vs. 7.1%, p = 0.275). After propensity score matching, there was still no difference in incidences of recall of tracheal extubation (7.1% vs. 7.0%, p = 0.853). Conclusion: In conclusion, when supervised by an anesthetist, resident extubations are no more likely to result in recall than anesthetist extubations.

Resumo Justificativa e objetivos: A recordação da emergência da anestesia é reconhecida como um dos tipos de memória da anestesia. Excluindo a extubação planejada com o paciente acordado, acredita-se que a memória não intencional durante a extubação traqueal seja o resultado de manejo inadequado da anestesia; portanto, a incidência pode estar relacionada com a experiência dos anestesistas. Para avaliar se a incidência de memória durante a extubação traqueal está relacionada com a experiência dos anestesistas, comparamos a incidência de memória durante a extubação traqueal entre pacientes tratados por residentes de anestesia ou por anestesistas experientes. Métodos: Estudo retrospectivo de revisão de um registo institucional com 21.606 casos de anestesia geral, conduzido com a aprovação do Comitê de Ética. Todas as extubações traqueais foram feitas por residentes sob a supervisão de anestesistas. Para evitar o viés de canalização, a análise do índice de propensão foi usada para gerar um grupo de casos pareados (manejo por residentes) e de controles (manejo por anestesistas), obtiveram-se 3.475 pares combinados de pacientes. A incidência de memória durante a extubação traqueal foi comparada com os desfechos primários. Resultados: Na população não pareada, não houve diferença na incidência de memória durante a extubação traqueal entre o manejo feito por residentes e anestesistas (6,5% vs. 7,1%, p = 0,275). Mesmo após parear os escores de propensão, não observamos diferença na incidência de memória durante a extubação traqueal (7,1% vs. 7,0%, p = 0,853). Conclusão: Em conclusão, quando supervisionadas por um anestesista, as extubações feitas por residentes não são mais propensas a resultar em memória do que as extubações feitas por anestesistas.

[Anesthesia management by residents does not alter the incidence of recall of tracheal extubation: a teaching hospital-based propensity score analysis]. / A administração de anestesia por residentes não altera a incidência de memória da extubação traqueal: uma análise de pontuação de propensão baseada no ensino hospitalar.

BACKGROUND AND OBJECTIVES: The memory of emergence from anesthesia is recognized as one type of anesthesia awareness. Apart from planed awake extubation, unintentional recall of tracheal extubation is thought to be the results of inadequate anesthesia management; therefore, the incidence can be related with the experience of anesthetists. To assess whether the incidence of recall of tracheal extubation is related to anesthetists' experience, we compared the incidence of recall of tracheal extubation between patients managed by anesthesia residents or by experienced anesthetists. METHODS: This is a retrospective review of an institutional registry containing 21,606 general anesthesia cases and was conducted with the board of ethical review approval. All resident tracheal extubations were performed under anesthetists' supervision. To avoid channeling bias, propensity score analysis was used to generate a set of matched cases (resident managements) and controls (anesthetist managements), yielding 3,475 matched patient pairs. The incidence of recall of tracheal extubation was compared as primary outcomes. RESULTS: In the unmatched population, there was no difference in the incidences of recall of tracheal extubation between resident management and anesthetist management (6.5% vs. 7.1%, p=0.275). After propensity score matching, there was still no difference in incidences of recall of tracheal extubation (7.1% vs. 7.0%, p=0.853). CONCLUSION: In conclusion, when supervised by an anesthetist, resident extubations are no more likely to result in recall than anesthetist extubations.

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

BACKGROUND: Respiratory therapists (RTs) routinely care for patients with life-limiting illnesses and in some hospitals are responsible for terminal extubations. Data on how such experiences affect RTs are scarce. The objective of this work was to survey RTs at 2 academic medical centers about their experiences caring for patients with terminal extubations. METHODS: An online survey was distributed to the hospitals' RTs. Survey data included demographics and experiences with end-of-life care and terminal extubations. The survey was derived from previously published questionnaires plus input from hospital RT leaders. RESULTS: Sixty-five of 173 RTs (37.6%) responded. Of these, 42.4% were ≥50 y old, and 62.7% were female. 20.3% had ≤5 y experience; 52.5% had ≥16 y. 93.8% self-reported being involved in at least one terminal extubation; of those, 36.1% reported performing ≥20. Nearly half (47.5%) wanted to be involved in family meetings discussing terminal extubations, but just 6.6% were frequently involved. Only 32.3% felt that they received adequate education regarding terminal illness in RT school; 32.3% reported gathering this knowledge while working. 60.0% wanted more formal education around terminal patient care. 27.9% reported sometimes being uncomfortable with performing a terminal extubation; most of these rarely felt that they had the option not to perform the extubation. CONCLUSIONS: RTs are rarely involved in end-of-life discussions despite a desire to be, and they experience situations that generate discomfort. There is demand for more formal RT training around care for terminal patients. Clinical protocols that involve RTs in meetings before ventilator withdrawal should be considered.

ICU physicians' and nurses' perceptions of terminal extubation and terminal weaning: a self-questionnaire study.

PURPOSE: Terminal extubation (TE) and terminal weaning (TW) are the methods available for withdrawing mechanical ventilation. Perceptions of TE and TW by intensive care unit (ICU) staff may influence bedside practices and the feasibility of studies comparing these methods. METHODS: From January to June 2013, 5 nurses and 5 physicians in each of 46 (out of 70, 65.7 %) French ICUs completed an anonymous self-questionnaire. Clusters of staff members defined by perceptions of TE and TW were identified by exploratory analysis. Denominators for computing percentages were total numbers of responses to each item; cases with missing data were excluded for the relevant item. RESULTS: Of the 451 (98 %) participants (225 nurses and 226 physicians), 37 (8.4 %) had never or almost never performed TW and 138 (31.3 %) had never or almost never performed TE. A moral difference between TW and TE was perceived by 205 (45.8 %) participants. The exploratory analysis identified three clusters defined by personal beliefs about TW and TE: 21.2 % of participants preferred TW, 18.1 % preferred TE, and 60.7 % had no preference. A preference for TW seemed chiefly related to unfavorable perceptions or insufficient knowledge of TE. Staff members who preferred TE and those with no preference perceived TE as providing a more natural dying process with less ambiguity. CONCLUSION: Nearly two-fifths of ICU nurses and physicians in participating ICUs preferred TW or TE. This finding suggests both a need for shared decision-making and training before performing TE or TW and a high risk of poor compliance with randomly allocated TW or TE.

[Model for unplanned self extubation of ICU patients using system dynamics approach].

PURPOSE: In this study a system dynamics methodology was used to identify correlation and nonlinear feedback structure among factors affecting unplanned extubation (UE) of ICU patients and to construct and verify a simulation model. METHODS: Factors affecting UE were identified through a theoretical background established by reviewing literature and preceding studies and referencing various statistical data. Related variables were decided through verification of content validity by an expert group. A causal loop diagram (CLD) was made based on the variables. Stock & Flow modeling using Vensim PLE Plus Version 6.0 b was performed to establish a model for UE. RESULTS: Based on the literature review and expert verification, 18 variables associated with UE were identified and CLD was prepared. From the prepared CLD, a model was developed by converting to the Stock & Flow Diagram. Results of the simulation showed that patient stress, patient in an agitated state, restraint application, patient movability, and individual intensive nursing were variables giving the greatest effect to UE probability. To verify agreement of the UE model with real situations, simulation with 5 cases was performed. Equation check and sensitivity analysis on TIME STEP were executed to validate model integrity. CONCLUSION: Results show that identification of a proper model enables prediction of UE probability. This prediction allows for adjustment of related factors, and provides basic data do develop nursing interventions to decrease UE.

Model for Unplanned Self Extubation of ICU Patients Using System Dynamics Approach

PURPOSE: In this study a system dynamics methodology was used to identify correlation and nonlinear feedback structure among factors affecting unplanned extubation (UE) of ICU patients and to construct and verify a simulation model. METHODS: Factors affecting UE were identified through a theoretical background established by reviewing literature and preceding studies and referencing various statistical data. Related variables were decided through verification of content validity by an expert group. A causal loop diagram (CLD) was made based on the variables. Stock & Flow modeling using Vensim PLE Plus Version 6.0b was performed to establish a model for UE. RESULTS: Based on the literature review and expert verification, 18 variables associated with UE were identified and CLD was prepared. From the prepared CLD, a model was developed by converting to the Stock & Flow Diagram. Results of the simulation showed that patient stress, patient in an agitated state, restraint application, patient movability, and individual intensive nursing were variables giving the greatest effect to UE probability. To verify agreement of the UE model with real situations, simulation with 5 cases was performed. Equation check and sensitivity analysis on TIME STEP were executed to validate model integrity. CONCLUSION: Results show that identification of a proper model enables prediction of UE probability. This prediction allows for adjustment of related factors, and provides basic data do develop nursing interventions to decrease UE.

Humane terminal extubation reconsidered: the role for preemptive analgesia and sedation.

Patient comfort is not assured by common practices for terminal extubation. Treatment guidelines suggest minimizing dosage of opioids and sedatives. Multiple lines of evidence indicate that clinicians are limited in their ability to recognize distress in such patients and tend to undermedicate patients in distress. Yet suffering of any significant degree should be unacceptable. For painful procedures, such as surgery, the analogous practice of postponing anesthesia until the patient evidences discomfort would never be tolerated. Waiting for signs of suffering before initiating excellent analgesia and sedation inexorably subjects patients to distress. Therefore, when death is inevitable and imminent after extubation, suffering should be anticipated, concerns about respiratory depression dismissed, and vigorous preemptive deep sedation or anesthesia provided.