Study seeks to optimize comfort for patients removed from ventilators at end of life

June 01, 2020

A paper recently published online in the journal Chest reports on a study of the palliative ventilator withdrawal (PVW) procedure performed in intensive care units (ICU) at end of life. The study's goal was to determine the level of distress patients experience and identify treatments that could bring relief. Findings show that up to one-third of PVW patients experience an episode of rapid breathing called tachypnea as a marker of distress, and administration of opiates before PVW could help with symptom control. Corey Fehnel, M.D., M.P.H., a palliative care researcher in the Hinda and Arthur Marcus Institute for Aging Research at Hebrew SeniorLife, and Assistant Professor of Neurology at Harvard Medical School, is lead author on the paper.

On average, nearly one in five Americans will die in an ICU each year, and many of these deaths occur after the decision has been made to extubate and move from curative- to comfort-focused care. Although numerous professional societies and patient groups have advocated for improved management of ventilated ICU patients transitioning to palliative care, the process of PVW and the discomfort that patients experience has remained understudied. As a result, the practice varies widely across ICUs, and little is known about the indicators of patient distress and how to better control symptoms.

Monitoring symptoms of distress among hospitalized COVID-19 patients at end of life presents even more of a challenge. COVID-19 patients who are intubated on mechanical ventilation require providers to observe special aerosolized droplet isolation precautions. They must wear N95 masks, face shields, hats, gowns, and run HEPA filters in the room when opening the "circuit" to the ventilator or performing procedures, including extubation. These precautions make it difficult for critically ill patients to use non-verbal cues as a means of communication with their care providers.

In addition, patients are physically isolated with similar patients, and providers try to limit the number of times they enter the patient's room to prevent transmission of the virus. But most importantly, families are not allowed in the hospital to be with these patients during extubation, and they are an important part of easing patient distress and assuring patient comfort at end of life. Taken all together, the combined effect is a perfect storm of barriers to effective symptom assessment for these patients.

"We fervently hope that all patients will be comfortable at end of life in the ICU but unfortunately some people experience discomfort, and we identified one tactic to alleviate that distress," said Dr. Fehnel. "The results of this study, which point to administration of opiates before PVW and in anticipation of distress, could help with symptom control and can be readily applied to COVID-19 and all critically ill patients during this time of great need."
-end-
Dr. Fehnel's research is supported by grant support from the National Institute on Aging: NIA K23AG066929 and R03AG060186. In addition to the Marcus Institute for Aging Research, researchers from Beth Israel Deaconess Medical Center, Wayne State College of Nursing, and University of Pittsburg Medical Center collaborated on this study.

About the Hinda and Arthur Marcus Institute for Aging Research

Scientists at the Hinda and Arthur Marcus Institute seek to transform the human experience of aging by conducting research that will ensure a life of health, dignity, and productivity into advanced age. The Marcus Institute carries out rigorous studies that discover the mechanisms of age-related disease and disability; lead to the prevention, treatment, and cure of disease; advance the standard of care for older people; and inform public decision-making.

About Hebrew SeniorLife

Hebrew SeniorLife, an affiliate of Harvard Medical School, is a national senior services leader uniquely dedicated to rethinking, researching, and redefining the possibilities of aging. Based in Boston, the nonprofit, non-sectarian organization has provided communities and healthcare for seniors, research into aging, and education for geriatric care providers since 1903. For more information about Hebrew SeniorLife, visit http://www.hebrewseniorlife.org, follow us on Twitter @H_SeniorLife, like us on Facebook, or read our blog.

Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research

Related Palliative Care Articles from Brightsurf:

Palliative care needed across China for everyone who needs it -- study
Palliative care should extend across China and pay more attention to managing non-malignant disease -- integrated within the country's healthcare system and available to everyone who needs it, according to a new study.

New palliative care model shown to reduce costs without compromising on quality of care
Findings from a large-scale clinical trial testing a new palliative care model have shown to be lower cost, viewed positively by patients and their carers while showing no difference in patient-reported outcomes when compared with standard care.

Palliative Care in emergency departments during COVID-19 pandemic
The clinical characteristics and outcomes of patients who received intervention by a COVID-19 palliative care response team are examined in this case series.

Palliative care for patients with cancer in COVID-19 era
The considerations and challenges affecting the palliative care specialty and delivery of palliative care in the COVID-19 era, as well as potential solutions, are discussed in this Viewpoint.

To face coronavirus disease 2019, surgeons must embrace palliative care
This Viewpoint describes the relevance of a palliative care approach to surgery during the coronavirus disease 2019 pandemic.

Call for palliative care to be adapted for severely ill Covid-19 patients
Emergency-style palliative care needs to implemented to meet the needs of Covid-19 patients who wouldn't benefit from a ventilator say researchers.

A COVID-19 palliative care pandemic plan: An essential tool
Palliative care physicians have created a coronavirus disease 2019 (COVID-19) palliative care plan as an essential tool to provide care and help manage scare resources during the pandemic.

MAiD is not driven by socioeconomic vulnerability or poor access to palliative care
A new study of people who received medical assistance in dying (MAiD) in Ontario found that about three-quarters were cared for by palliative care practitioners at the time of their request for MAiD, and MAiD recipients were younger, wealthier and more likely to be married than the general population at time of death.

Palliative vs. standard care for Parkinson's disease
This randomized clinical trial that included 210 patients with Parkinson's disease and related disorders and 175 caregivers examined whether outpatient palliative care was associated with better patient or caregiver outcomes compared with standard care.

Palliative care in hospitals linked to decrease in use of ICU; treatment intensity
A new study shows that implementing hospital-based palliative care services in New York State reduces treatment intensity at the end of life for hospitalized patients.

Read More: Palliative Care News and Palliative Care Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.