Withdrawal of ventilatory support outside the intensive care unit: guidance for practice

Abstract

ObjectiveTo review the work of one tertiary paediatric palliative care service in facilitating planned withdrawal of ventilatory support outside the intensive care setting, with the purpose of developing local guidance for practice.MethodsRetrospective 10-year (2003–2012) case note review of intensive care patients whose parents elected to withdraw ventilation in another setting. Demographic and clinical data revealed common themes and specific incidents relevant to local guideline development.Results18 children (aged 2 weeks to 16 years) were considered. Three died prior to transfer. Transfer locations included home (5), hospice (8) and other (2). Primary pathologies included malignant, neurological, renal and respiratory diseases. Collaborative working was evidenced in the review including multidisciplinary team meetings with the palliative care team prior to discharge. Planning included development of symptom management plans and emergency care plans in the event of longer than anticipated survival. Transfer of children and management of extubations demonstrated the benefits of planning and recognition that unexpected events occur despite detailed planning. We identified the need for local written guidance supporting healthcare professionals planning and undertaking extubation outside the intensive care setting, addressing the following phases: (i) introduction of withdrawal, (ii) preparation pretransfer, (iii) extubation, (iv) care postextubation and (v) care postdeath.ConclusionsPlanned withdrawal of ventilatory support outside the intensive care setting is challenging and resource intensive. The development of local collaborations and guidance can enable parents of children dependent on intensive care to consider a preferred place of death for their child, which may be outside the intensive care unit.

Palliative Care Consultation to Assist Discussion of Ventilator Withdrawal in a Medical Center in Taiwan

“…Dyspnea was relieved by fentanyl and dormicum, and for comfort care, we prescribed pre-withdrawal medications earlier than in previous studies [16]. In our medical records, dyspnea, agitation, and respiratory secretions were most frequently observed by nurses, which was similar in previous study reports [17].…”

Transferring critically ill babies and children home to die from intensive care

“…Facilitating the preferred choice in place of death for babies and children is increasingly being advocated . A small number of papers have described centres transferring critically ill babies and/or children home to die and argue that health care professionals (HCPs) consider this to be a viable and meaningful option to offer families in ICUs (). However, this evidence is limited to case reports and the experience of very few paediatric or neonatal ICUs.…”

Pediatric Critical Care Transport as a Conduit to Terminal Extubation at Home: A Case Series*

“…Laddie et al (7) reported the largest cohort of 15 children (11 from PICU, 4 from NICU) who died after terminal extubation outside of the ICU. They identified the importance of pre-planning, effective communication with families and team members, and early palliative care involvement.…”