Palliative extubation: case analysis in an Intensive Care Unit

Abstract

Current technological advancements have allowed for the prolongation of the dying process, especially in Intensive Care Units (ICU). This has increased the need for decisions on the limitation of therapeutic effort (LTE), such as the use of palliative extubation that, although difficult from an emotional standpoint, has legal and ethical justifications, and has increased family acceptance. The objective was to evaluate the clinical and demographical profile of patients submitted to palliative extubation (PT) in the ICU of the University Hospital of the Universidade Federal de Santa Catarina (HU/ UFSC), Brazil. This was a historical cohort whose data were obtained from forms filled out by critical care doctors from the Hospital Death Commission at the HU/UFSC. Patients submitted to LTE that died between January 2011 and December 2014 were included in the study. The use of PT and clinical and epidemiological data were collected. LTE was indicated in 374 (53.8%) patients, with 23 (6.1%) receiving PT. Average age of patients undergoing PT was 73.8 years; 10 patients were over 60, and 9 were over 80 years of age. Ten (43.4%) patients had been previously in the ICU. The average time from checking in at the ICU and extubation was 4.4 days, and between extubation and death it was 2.5 days. Neurological disease was the main cause of death of patients subjected to PT. All family members were aware of the extubation. Family members from 2 families witnessed the extubation. Morphine was the most common analgesic prescribed. It is concluded that patients submitted to PT were older, with neurological diseases, and the average time from extubation to death was 2.5 days ResumoO desenvolvimento tecnológico do mundo atual tem permitido o prolongamento do morrer, principalmente em unidades de terapia intensiva (UTI). Torna-se crescente a necessidade de decisões de limite de esforço terapêutico (LET), do qual se destaca a extubação paliativa (EP), que embora difícil de ser aceita do ponto de vista emocional, tem respaldo ético-legal e aumenta a satisfação familiar. O estudo teve como objetivo avaliar o perfil clínico-demográfico dos pacientes extubados paliativamente (ExPl) na UTI do HU/UFSC. Trata-se de coorte histórico, cujos dados foram coletados através das fichas preenchidas por médicos intensivistas que constituem a Comissão de Óbito da instituição. Foram incluídos os pacientes que morreram na UTI/HU/UFSC, após indicação de LET, entre janeiro/2011 e dezembro/2014. Foram selecionados os pacientes que foram ExPl, sendo anotados seus dados clínicos e epidemiológicos. LET foi apontado em 374 (53,8%) pacientes, sendo 23 (6,1%) ExPl. A média da idade dos ExPl foi de 73,8 anos, 10 tinham mais de 60 e 9 mais de 80 anos. Dez (43,4%) pacientes já haviam sido internados previamente em UTI. O tempo médio entre a internação-extubação foi 4,4 dias e entre extubação-morte foi de 2,5 dias. Doença neurológica foi a principal causa da morte dos pacientes ExPl. Todos os familiares estavam cientes da EP. Familiares de 2 pacientes acompa...

Palliative extubation experience in a community hospital in southern Brazil

“…Most family members would likely prefer the choice to shorten the dying process of the patients by withdrawing the ventilator 18 . In Brazil, however, palliative extubation is seldom performed 3 – 5 : 50.2% of Brazilian intensivists admit fear of litigation, although over 75% claim to have received specific palliative care training 19 . A survey 20 collected responses from 105 ICU physicians in Brazil in 2012 regarding a case vignette of a critically ill patient with post-cardiac arrest encephalopathy and sepsis: none would perform palliative extubation.…”

Extubação Paliativa em Pacientes Terminais: Revisão Integrativa

“…Segundo estudo realizado na unidade de terapia intensiva (UTI) de um Hospital Universitário, grande parte dos pacientes, que foram submetidos à extubação paliativa, é de idosos, acometidos por doenças neurológicas, tendo como tempo de vida pós-procedimento variável de minutos a dias, porém sua maioria foi a óbito após 24 horas. Rebelatto e Moritz 22 pós-extubação está relacionado à gravidade da doença, e não à retirada do suporte ventilatório. Já subsequente a este estudo, em outra pesquisa, observou-se que grande parte dos pacientes analisados foi a óbito no local onde foi realizada a extubação paliativa, no próprio hospital.…”

The perception of oncology ICU professionals regarding the practice of palliative extubation

“…The statements showed that oncology ICU professionals were familiar with the concept of palliative extubation, as described in the literature. It involves removing the invasive mechanical ventilator in the face of an irreversible clinical condition, with the aim of promoting comfort and relief for the patient, allowing the disease to take its natural course [1][2][3][4][6][7][8][9][10][11] .…”

“…As the literature itself points out, professionals still associate the dyspneic patient's well-being with the provision of oxygen support or invasive ventilation; or they relate palliative extubation to shortening the patient's life span and inducing death, often making difficult an effective communication between team members themselves and with the family 2,5,10,13,19 .…”

“…Technological progress has been accompanied by life-prolonging resources that raise bioethical questions about living and dying, such as the discussion of withdrawing support when suffering outweighs the benefits of a treatment, designating procedures as futile. Among the alternatives for therapeutic limits, palliative extubation (PE) stands out, defined by the interruption of mechanical ventilation in patients with irreversible diseases when the aim of the treatment is to provide care, comfort and allow the disease to take its natural course until death [1][2][3][4][5][6] .…”