End-of-life decision-making in respiratory intermediate care units: a European survey

Abstract

A survey was performed on behalf of the European Respiratory Society to assess end-of-life practices in patients admitted to European respiratory intermediate care units and high dependency units over a 6-month period.A 33-item questionnaire was sent by e-mail to physicians throughout Europe and the response rate was 28 (29.5%) out of 95. A total of 6,008 patients were admitted and an end-of-life decision was taken in 1,292 (21.5%). The mortality rate in these patients was 68% (884 out of 1,292).The patients received similar proportions of withholding of treatment (298 (23%) out of 1292), do-not-resuscitate or do-not-intubate orders (442 (34%) out of 1,292) and noninvasive mechanical ventilation as the ceiling of ventilatory care (402 (31%) out of 1,292). Withdrawal of therapy was employed in 149 (11%) out of 1,292 patients and euthanasia in one. Do-not-intubate/do-notresuscitate orders were more frequently used in North compared with South Europe. All of the 473 competent patients directly participated in the decision, whereas, in 722 (56%) out of 1,292 cases, decision-making was reported to be shared with the nurses.In European respiratory intermediate care units and high dependency units, an end-of-life decision is taken for 21.5% of patients admitted. Withholding of treatment, do-not-intubate/do-notresuscitate orders and noninvasive mechanical ventilation as the ventilatory care ceiling are the most common procedures. Competent patients are often involved, together with nurses.

Chronic Obstructive Pulmonary Disease: Official diagnosis and treatment guidelines of the Czech Pneumological and Phthisiological Society; a novel phenotypic approach to COPD with patient-oriented care

“…As COPD progresses, the initial classification . A patient can be considered being at a terminal stage when the life expectancy is less than 6 months, provided that the following condition also applies: dyspnoea at rest, which does not respond to pharmacotherapy resulting in a daily regime in bed + armchair; gradual clinical progression of the disease and permanent presence of hypoxemia 54,55 . If the patient's state closely approaches death (in weeks/ days/hours), it is called end-of-life phase of the disease.…”

“…no further transfusions, no further catecholamine support, no use of elimination methods, the absence of surgical interventions) De-escalation or withdrawal of currently supplied care -for example the discontinuation of oxygen substitution (i.e. decrease of FiO 2 to 21%), discontinuation of catecholamine support, weaning from the ventilation support 54,55 . An important part of palliative care is the administration of opioids (orally, transdermally or parenterally), first justified in discussion with the patient's family or the patient himself/herself.…”

Palliative and end-of-life care for patients with severe COPD

“…The use of noninvasive ventilation for patients who choose to forego invasive mechanical ventilation is relatively common in Europe, with approximately one third of patients who receive end-of-life care in the hospital receiving noninvasive ventilation as the most aggressive form of ventilation before death [78]. A recent Society of Critical Care Medicine Task Force provided a systematic approach to considering noninvasive ventilation in palliative care settings, and concluded that although noninvasive ventilation may be appropriate as a form of life support for patients who choose to forego invasive ventilation, current literature does not support the routine use of noninvasive ventilation for the sole purpose of palliation of symptoms [79].…”

Nonpharmacological treatment and relief of symptoms in COPD

“…NPPV is an alternative to invasive ventilation for symptom relief in end-stage COPD [106][107][108], and a recent European survey of respiratory intermediate care units reported a frequency of use and its role in almost a third of patients among those with poor life expectancy [109]. NPPV reduces dyspnoea even in the absence of hypercapnic respiratory failure [110].…”