WELL-BEING AND ADVANCE DIRECTIVES AMONG PROLONGED MECHANICAL VENTILATION PATIENTS AT HOME VERSUS HOSPITAL

Abstract

Despite increasing numbers of older patients requiring Prolonged Mechanical Ventilation (PMV), little is known concerning their mood, well-being, distressing symptoms and attitudes towards ventilation. Furthermore differences may exist according to place of care- whether Home Hospital or Hospital Long Term Care (HLTC). These issues were addressed using the revised Edmonton Symptom Assessment System (r-ESAS)(10 items, max severity score=100), and Short Geriatric Depression Scale, in a study of the majority of PMV patients (n=120/123) aged ≥18 (range 18-96 years) all Clalit Health Service insurees, in Jerusalem. Communicative patients were interviewed (40/46 at home, 22/74 in HLTC, average age 54 vs.73 years, p<0.01). The following symptoms (dichotomized to “not-a-problem”/“problematic”) were frequently reported as “not-a-problem” among patients (Home,HLTC): tiredness (59%,58%), poor appetite (95%,90%), pain (69%,84%), drowsiness (77%,90%), nausea (85%,84%), and shortness of breath (82%,90%). General well-being (categorized to good/mild/moderate/severe impairment) was reported more frequently as good or mildly impaired at Home vs. HLTC (54% vs.26%), as was lower frequency of depression (34.4% vs. 44.4%, p=0.049). The total r-ESAS score was similar irrespective of setting: Home-24.9/100 (inter quartile range {IQR} 13.5-32.5) vs. HLTC-23.7/100 (IQR 17.5-32),p=0.74. The majority (119/120) of patients were without advanced directives prior to initiation of PMV. When asked if they had to choose again, 82% and 91% of communicative patients at home vs. HLTC would opt again for ventilation, as would 75% of caregivers of uncommunicative patients. Our findings emphasize the resilience and low levels of distressing symptoms among PMV patients, and may contribute to the decision-making process concerning advanced directives.