Background Withdrawal of non invasive ventilation (NIV) in patients with motor neurone disease has been well documented. However, little is published about the process in patients using it acutely for respiratory failure associated with a primary respiratory disease.
Aim This audit provides a retrospective collation of cases in which NIV was withdrawn in patients commenced on the treatment acutely in the hospital setting.
Methods Cases were identified using the search function of the electronic palliative care notes between April 2016 and April 2017. Patients identified as undergoing withdrawal of NIV or discussion about NIV withdrawal had hospital notes obtained for analysis. Nine patients fitted the criteria. Six underwent a planned withdrawal of treatment. Hospital notes and drug charts were reviewed to provide data on the withdrawal process.
Results Average length of hospital stay was 8.5 days. Palliative care referrals were made on average 2.57 days prior to withdrawal with 57% of cases being referred the same day. Decision to withdraw was documented on the same day withdrawal took place in 100%. The decision was discussed with 50% of patients and 83% of families by a range of healthcare professionals. Ventilator weaning took place in 50%. Medication administration demonstrated a range of practice. Pre-medication was documented in 33%, post withdrawal bolus doses were required in 50%. Administration route was a mix of IV bolus, SC bolus (dose range of 1–7.5 mg of midazolam and 3–7.5 mg of morphine) and syringe driver (average starting dose 13.5 mg midazolam and 12.5 mg morphine). 71% of patients died within 24 hours of ventilation withdrawal. No patient survived >48 hours. All died in hospital.
Conclusion Decision making and treatment withdrawal in this patient group is rapid. Practice of withdrawal and pharmacological intervention is varied. This highlights the need to develop guidance for the process of NIV withdrawal in the hospital setting and the need for clear standards of documentation when undertaking withdrawal decisions discussions.
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