Process of Withdrawal of Mechanical Ventilation at End of Life in the ICU: Clinician Perceptions

Abstract

BackgroundNearly a quarter of all Americans die in the intensive care unit (ICU). Many of their deaths are anticipated and occur after withdrawal of mechanical ventilation (WMV). Yet, there are few data on which to base best practices for interdisciplinary ICU teams to conduct WMV. Research QuestionTo investigate the perceptions of current WMV practices among ICU clinicians, and gain their opinions of processes that might improve the practice of WMV at end of life in the ICU. Study Design and MethodsWe conducted a prospective two-center observational study in Boston, MA of the withdrawal of mechanical ventilation (OBSERVE-WMV) designed to better understand the perspectives of clinicians and experience of patients undergoing WMV. This report focuses on analyses of qualitative data obtained from in-person surveys administered to the ICU clinicians (nurses, respiratory therapists, physicians) caring for these patients. Surveys assessed a broad range of clinician perspectives on planning, and key processes required for WMV. This analysis utilized independent open, inductive coding of responses to open-ended questions. Initial codes were reconciled iteratively, and then organized and interpreted using a thematic analysis approach. We assessed opinions on how WMV could be improved for individual patients and the ICU as a whole. ResultsAmong 456 eligible clinicians, 312 in-person surveys were completed by clinicians caring for 152 patients who underwent WMV. Qualitative analyses identified two main themes characterizing high quality WMV processes: good communication (e.g. mutual understanding of family preferences) between the ICU team and family, and medical management (e.g. planning, availability of ICU team) that minimizes patient distress. Team member support was identified as an essential process component in both themes. InterpretationClinician perceptions of the appropriateness or success of WMV prioritize the quality of team and family communication and patient symptom management. Both are modifiable targets of interventions aimed at optimizing overall WMV.