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Non-invasive advanced respiratory support in end-of-life care and symptom management: systematic review
  1. David Wenzel1,2,
  2. Lucy Bleazard3,
  3. Coral Jayne Pepper4,
  4. Eleanor Wilson5 and
  5. Christina Faull2
  1. 1Palliative Care, University Hospitals of Leicester NHS Trust, Leicester, Leicester, UK
  2. 2Palliative Care, LOROS Hospice, Leicester, UK
  3. 3School of Health Sciences, University of Leicester, Leicester, UK
  4. 4Library and Information Service, University Hospitals of Leicester NHS Trust, Leicester, UK
  5. 5School of Health Sciences, University of Nottingham, Nottingham, UK
  1. Correspondence to Dr David Wenzel, Palliative Care, University Hospitals of Leicester NHS Trust, Leicester, LE5 4PW, UK; David.wenzel{at}


Objectives To narrate the canon of knowledge around symptom control at end of life for patients using, or having recently used, non-invasive advanced respiratory support (NARS) at end of life for respiratory failure.

Methods A systematic review forming a narrative synthesis from a wide range of sample papers from Medline, Embase, CINAHL, Emcare, Cochrane and OpenGrey databases. A secondary search of grey literature was also performed with hand searching reference lists and author citations. The review was undertaken using the ENTREQ checklist for quality.

Results In total, 22 studies were included in the synthesis and four themes were generated: NARS as a buoy (NARS can represent hope and relief from the symptoms of respiratory failure), NARS as an anchor (NARS brings significant treatment burden), Impact on Staff (uncertainty over the balance of benefit and burden as well as complex patient care drives distress among staff providing care) and the Process of Withdrawal (withdrawal of therapy felt to be futile exists as discrete event in patient care but is otherwise poorly defined).

Conclusion NARS represents a complex interplay of hope, symptom control, unnaturally prolonged death and treatment burden. The literature captures the breadth of these issues, but further, detailed, research is required in almost every aspect of practice around end-of-life care and NARS—especially how to manage symptoms at the end of life.

  • chronic obstructive pulmonary disease
  • COVID-19
  • end of life care
  • respiratory conditions
  • dyspnoea

Data availability statement

Data are available upon request.

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  • Contributors DW and CF conceptualised and developed the project. The protocol was authored by DW and reviewed/edited by CF. Data collection tools were designed by all authors. Data collection was performed principally by DW and CP. Database creation was principally by DW, supported by LB and CP. Data analysis was performed principally by DW with support from LB, EW and CF (contribution level in order). Thematic analysis was performed equally by DW and LB with further contribution from CF and EW. The primary report was authored by DW with editing and review by EW, CF, CP and LB (contribution level in order). DW acts as guarantor for the study taking responsibility for the final output having held full access to the data and made the decision to publish.

  • Funding The lead author’s current posting, academic clinical fellow, is a funded role by the National Institute of Health Research (NIHR). Funding award reference ACF-2019-11-007.

  • Disclaimer The NIHR had no input in study creation, design or reporting.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.