Terminal Withdrawal of Life-Sustaining Supplemental Oxygen

Halpern, Scott D.; Hansen‐Flaschen, John

doi:10.1001/jama.296.11.1397

Cited by 7 publications

(5 citation statements)

References 19 publications

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“…Occasionally, a patient's suffering is so great that even noninvasive, comfort-promoting treatments are regarded as excessively burdensome, precisely because they may sustain life. Because they find themselves in a state worse than death, they may wish oxygen discontinued 3 or a pacemaker turned off. 4 For most patients, ''comfort'' is measured in terms of pain and suffering caused either by the underlying disease or by its treatment.…”

Section: Introductionmentioning

confidence: 99%

Potential Burdens of Low-Tech Interventions Near the End of Life

Gillick

2009

Journal of Pain and Symptom Management

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Decisions to forgo medical interventions are typically made by balancing their benefits and burdens. Often omitted from consideration is the environment in which the proposed treatment is to be administered. A case is presented of a 77-year-old man with end-stage pulmonary fibrosis who developed dependence on high flow oxygen, a technology unavailable in his community outside the hospital setting. Medical staff struggled with the appropriateness of discontinuing the oxygen because it was not the face mask that the patient found burdensome, rather the setting in which the treatment was provided. The case is discussed from the perspective of clinical ethics, organizational ethics, and the law.

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Section: Introductionmentioning

confidence: 99%

Potential Burdens of Low-Tech Interventions Near the End of Life

Gillick

2009

Journal of Pain and Symptom Management

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“…Future studies should also identify the optimal treatment pathway to utilize when patients using HFNC oxygen fail this therapy (eg, transition to NPPV versus intensifying palliative opioids) as well as the optimal process to withdraw palliative HFNC oxygen. 22 Identifying which patient populations may benefit from different treatment pathways should also be considered as different treatment strategies may be more beneficial in different patient populations (eg, based on cause and sever- Scoring: low risk of bias: total score, 3-5 points; high risk of bias: total score, 0-2 points ity of acute respiratory failure). In addition, it should be noted that the primary goal of care might affect which outcomes are the most important to measure.…”

Section: Discussionmentioning

confidence: 99%

“…Future studies in patients with acute respiratory failure and DNI and/or DNR orders should identify which treatment modality (HFNC oxygen compared with other modalities, such as NPPV, conventional oxygen, with or without palliative opioids) impacts outcomes, such as dyspnea reduction while maintaining an alert mental status, short‐ and long‐term quality of life in survivors, and quality of death in nonsurvivors. Future studies should also identify the optimal treatment pathway to utilize when patients using HFNC oxygen fail this therapy (eg, transition to NPPV versus intensifying palliative opioids) as well as the optimal process to withdraw palliative HFNC oxygen 22 . Identifying which patient populations may benefit from different treatment pathways should also be considered as different treatment strategies may be more beneficial in different patient populations (eg, based on cause and severity of acute respiratory failure).…”

Section: Discussionmentioning

confidence: 99%

High‐Flow Nasal Cannula Oxygen in Patients with Acute Respiratory Failure and Do‐Not‐Intubate or Do‐Not‐Resuscitate Orders: A Systematic Review

Wilson

Mittal

Dobler

et al. 2019

Journal of Hospital Medicine

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BACKGROUND AND OBJECTIVES: High-flow nasal cannula (HFNC) oxygen may provide tailored benefits in patients with preset treatment limitations. The objective of this study was to assess the effectiveness of HFNC oxygen in patients with do-not-intubate (DNI) and/or do-not-resuscitate (DNR) orders. METHODS: We conducted a systematic review of interventional and observational studies. A search was performed using MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science, from inception to October 15, 2018. RESULTS: We included six studies evaluating 293 patients. All studies had a high risk of bias. The hospital mortality rates of patients with DNI and/or DNR orders receiving HFNC oxygen were variable and ranged from 40% to 87%. In two before and after studies, the initiation of HFNC oxygen was associated with improved oxygenation and reduced respiratory rates. One comparative study found no difference in dyspnea reduction or morphine doses between patients using HFNC oxygen versus conventional oxygen. No studies evaluated quality of life in survivors or quality of death in nonsurvivors. HFNC was generally well tolerated with few adverse events identified. CONCLUSIONS: While HFNC oxygen remains a viable treatment option for hospitalized patients who have acute respiratory failure and a DNI and/or DNR order, there is a paucity of high-quality, comparative, effectiveness data to guide the usage of HFNC oxygen compared with other treatments, such as noninvasive ventilation, conventional oxygen, and palliative opioids.

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“…[76][77][78] Supplemental oxygen may relieve dyspnea in patients who are hypoxemic but should also be identified as a life-sustaining treatment, particularly as technologies such as high-flow oxygen delivery systems become more common. [79][80][81][82] Noninvasive ventilation can be used to relieve dyspnea for patients at EOL, particularly as a time-limited trial or for severe dyspnea that is not initially controlled by medications. [83][84][85][86] However, introducing life-sustaining treatments such as high-flow oxygen or noninvasive ventilation can create physical barriers and may send mixed signals for patients approaching EOL.…”

Section: Symptom Managementmentioning

confidence: 99%

Critical Care at the End of Life

Akgün

Kapo

Siegel

2015

Semin Respir Crit Care Med

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Intensive care unit (ICU) admission is common among patients approaching the end of their lives from acute as well as chronic life-limiting conditions. ICU providers are expected to have basic palliative care skills integrated into their routine practice. Palliative care skills can be applied to all ICU patients, regardless of prognosis, and may improve patient- and family-centered end of life (EOL) care in the ICU. Consultative palliative care models may be required for more complex palliative care needs including symptom management, medical decision making, and bereavement. This review discusses integrative and consultative palliative care models and the role of triggers for palliative care consultation, particularly when they are tailored to the needs of individual ICUs. We then review the evidence for providing several palliative care domains in the ICU and some of the ethical considerations surrounding EOL care in the ICU. Finally, we highlight the importance of self-care and peer support groups to mitigate the risk of burnout for clinicians providing EOL care in the ICU.

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Terminal Withdrawal of Life-Sustaining Supplemental Oxygen

Cited by 7 publications

References 19 publications

Potential Burdens of Low-Tech Interventions Near the End of Life

Potential Burdens of Low-Tech Interventions Near the End of Life

High‐Flow Nasal Cannula Oxygen in Patients with Acute Respiratory Failure and Do‐Not‐Intubate or Do‐Not‐Resuscitate Orders: A Systematic Review

Critical Care at the End of Life

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