Background There is little specific guidance for the process of withdrawing Non-Invasive Ventilation (NIV) for patients with Type 2 Respiratory Failure (T2RF), despite the potential for development of distressing symptoms. We evaluated current practice to assess the need for such guidance.
Method The Palliative Care Team at Northamptonshire Healthcare Foundation Trust and the Respiratory Team at Kettering General Hospital (KGH) worked collaboratively to review the medical notes of patients admitted to KGH between August 2018 and August 2019, who were coded for T2RF and NIV and had died on that admission. Exclusion criteria were use of invasive ventilation, patients who had not received NIV and those weaned off NIV after clinical improvement. 48 patients were identified; 26 were included, 8 were excluded due to the above criteria and 14 were excluded due to unavailability of medical notes.
Results Clear plans were documented regarding ceiling of treatment at initiation of NIV in 73%. Discussions concerning NIV withdrawal occurred with patients and/or relatives in 100% of cases, but patients were only involved in 15% due to confusion or reduced consciousness. The plan for withdrawal was documented in 58% of cases. 46% of patients were referred to the Palliative Care team, but 58% of Palliative Care referrals were made after NIV was withdrawn. There was significant variation in prescribing, with only six patients being given medication prior to NIV withdrawal. 69% had anticipatory end of life medications prescribed but there was variation in which opioid, antiemetic and antisecretory was used.
Conclusion The differences observed in practice regarding communication, medical management and the process of withdrawal show a lack of standardised approach. Maintaining individualised patient care is important, but there may be a place for structured guidance to ensure that conversations are had, the need for symptomatic relief prior to withdrawal is considered, and medications are prescribed in anticipation of potential distress.
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