How Long Can an Endotracheal Tube be Left in Place at the End-of-life?

Abstract

1.Outline the viability of leaving an endotracheal tube in place for months in a pediatric palliative care patient.2.Appraise the issues surrounding current “standards of care” for how long an endotracheal tube can be left in place.3.Discuss the ethical issues surrounding decision-making and conflict between treating teams and parents. I. Background. When children intubated for an acute illness are subsequently found to have a life-limiting condition, a frequent course is to withdraw life-support technologies. For personal, cultural, or religious reasons some families may not agree with extubation but may otherwise accept nonescalation of treatment and comfort measures. When extubation is not an option, there is little information in the literature on how long an endotracheal tube can remain unchanged in situ. This case describes a 20-month-old boy with a prolonged (8 months) intubation with the same endotracheal tube in place without any mechanical or technical complications. II. Case Description. Presentation was at 8 months of age with a 2 1/2-month history of decreased tone, arrest of milestone attainment, and failure to thrive. He was initially diagnosed with infantile botulism due to a stool culture positive for viable C botulinum Type A. Subsequently, genetic testing diagnosed Thimidine Kinase 2 deficiency, a mitochondrial depletion syndrome. At the time of diagnosis, he had been ventilated via an endotracheal tube for 3 months. Due to the severity of disease and ultimately fatal prognosis the treating team felt that prolonged ventilation was not in his best interests. The parents, however, refused extubation on cultural and religious grounds, but agreed to a nonescalation of life-support technologies with a focus on comfort and quality of life. He was transferred intubated and ventilated to the medical ward where he was cared for by his parents for 3 months. After 8 months of intubation, his parents asked for him to be extubated and allowed to die. III. Conclusion. Although not a first choice, when needed, an endotracheal tube can be kept in place longer than is commonly thought without deterioration of the tube. This case also highlights several ethical issues surrounding decision-making and conflict between parents and the treating team. Physical Aspects of Care