Palliative Extubation Research Articles

Unravelling the differences between observation and active participation in simulation-based education

Background In simulation-based education, the effectiveness of observation or active participation on the retention of knowledge and skills is uncertain. The aim of the study was to investigate knowledge retention, technical and non-technical skills and self-efficacy among observers and active participants in a simulated palliative extubation. Method We included medical and nursing undergraduates and residents. On the first day, participants were divided into observers and active participants, each with one participant from medical and nursing backgrounds. We presented a recorded lecture, followed by knowledge and self-efficacy tests for all participants before and after the simulation. After fourteen days, both groups actively participated in the scenario, without observers. We assessed technical and non-technical skills during the simulation and repeated the knowledge and self-efficacy tests after the training. Results Forty-four individuals participated in this study, half from each training programme. Knowledge improved after the first training in both groups, with a significant drop only for active participants after 14 days. Self-efficacy increased in both groups, being higher for the active participants. After 14 days, active participants performed better in technical skills compared to observers, but it was similar in both groups for non-technical skills. Conclusions Active participation seems superior to observation in the development of self-efficacy and the retention of technical skills. Observation may be superior to active participation in knowledge retention. Retention of non-technical skills appears to be similar with both observation and active participation. The findings have important implications for current simulation-based education, but further research is recommended.

Palliative Extubation Protocol

Introduction: Palliative Extubation (PE) is considered to be the discontinuation of mechanical ventilation in patients whose death is inevitable, prioritizing comfort and respecting the patient’s wishes. This study focuses on definitions, ethical, and legal issues, as well as challenges faced by healthcare professionals.Objective: To explore PE as part of the transition in care, emphasizing symptomatic relief and continuity of PalliativeCare. A protocol and checklist for PE is proposed to guide professionals through the process.Method: Review of definitions, ethical, and legal aspects and presentation of a protocol and checklist for PE. Description of PE methods, including withdrawal of ventilatory support and the complexity of the decision.Results: The decision for PE must respect bioethical principles, patient autonomy and consider prognostic factors. The importance of analgesia and sedation is highlighted.Discussion: Ethical and legal aspects, such as Resolution 1805/2006 of the Federal Council of Medicine support PE, emphasizing the dignity of the patient and the right to therapeutic refusal. The updating of the Code of Medical Ethics in 2018 reinforces the provision of palliative care in terminal illnesses.Conclusion: PE is a complex and delicate practice in Intensive Palliative Care. The review highlights the importance of ethical and legal considerations and specific care when making decisions about PE, emphasizing quality in the dying process and relief of suffering.

Attitudes of Patients with Advanced Chronic Illnesses Toward Palliative Extubation in a Country Where It Is Illegal.

Background: Palliative extubation (PE) is the cessation of mechanical ventilation (MV) during terminal illness. Although PE is widely practiced in many countries, it remains illegal in others. Attitudes toward PE of patients at the highest risk for MV were scarcely explored before. Objective: To assess the attitudes of patients with advanced chronic illnesses (ACI) toward PE and other end-of-life decisions in a country where PE is illegal. Design: A prospective observational study using questionnaire-based interviews. Setting/Subjects: Patients with ACI hospitalized between 2021 and 2022 in a large tertiary center. Attitudes toward PE and mechanical ventilation were evaluated. Predictors for favoring/opposing PE were analyzed using multivariate logistical regression models. Results: A total of 152 (40% female, 75 ± 11 years) patients were included. The most common ACIs were advanced heart failure (32%), metastatic malignancy (32%), and chronic obstructive pulmonary disease (22%). Around 132 patients (87%) supported the legalization of PE, and their main reason was to avoid pain and suffering (87%). Legalization of PE would change the decision to avoid mechanical intubation in 34% of the cases. Most patients thought that the decision to perform PE should be made by the patient's physician and primary caregiver collaboratively (64%). Religious observance was an independent predictor for opposing PE (adjusted odds ratio 0.18; 95% confidence interval 0.06-0.59; p < 0.01), whereas the type of ACI was not. Conclusion: Most admitted patients with ACIs support the legalization of PE. Such policy change could have major impact on patients' end-of-life preferences. At-risk patients should be the focus of future studies in this area.

The perception of oncology ICU professionals regarding the practice of palliative extubation

Introduction: Palliative extubation is an ethically and legally supported practice; however, there are still difficulties in understanding the concept, erroneously relating palliative extubation to euthanasia.Objective: To analyze the perception of oncology ICU professionals of a private hospital in São Paulo regarding palliative extubation procedure and the interfaces in the care provided by the team.Methods: This is a descriptive exploratory study with a qualitative approach, in which a semi-structured interview was used; and as a data processing technique, the Collective Subject Discourse (CSD), which analyses empirical data of a verbal nature, in order to configure a collective subject with a social discourse.Results: The analysis of the interviews culminated in 13 categories of discourse, which described the practice of palliative extubation in the oncology ICU, the insertion of palliative care, the difficulties that permeate the multi-professional team, and the approach to the family.Conclusion: The conceptual description of palliative extubation is well known by the team, as they know how to distinguish palliative extubation from euthanasia. However, there are difficulties in practical performance, which can have a direct impact on patient care, communication with the family and the safety and well-being of the professional involved.

Palliative Extubation in Pediatric Patients in the Intensive Care Unit and at Home: A Scoping Review.

This scoping review is aimed at systematically mapping the evidence on palliative extubation in the pediatric intensive care unit. MEDLINE, EBSCO, and Cochrane databases were searched for articles published between January 2018 and December 2022, in English. Critical appraisal of sources of evidence was done using the Joanna Briggs Institute tools. PRISMA guidelines for scoping reviews were followed. Six studies were included, with 366 patients, from the USA (n = 4), Brazil (n = 1), and Germany (n = 1). Three were high-quality studies, two were moderate, and one was a low-quality study. Most studies were retrospective analysis; two were narrative approaches; two were evidence-based recommendation and quality improvement project; one study was a prospective intervention. Symptom control is crucial pre- and postextubation. A checklist (symptom management and family support) and a postdebriefing template improve team communication and staff support postextubation. Critical care transports from the hospital are feasible to provide extubation at home. A framework addressing common planning challenges and resource management is recommended for extubation at home. The provision of pediatric palliative extubation is necessary since futile measures and prolongation of suffering violate the principle of nonmaleficence. Future research on this subject will result in more benefits for patients, parents, and professionals.

Palliative Extubation: A Discussion of Practices and Considerations.

Palliative extubation (PE), also known as compassionate extubation, is a common event in the critical care setting and an important aspect of end-of-life care.1 In a PE, mechanical ventilation is discontinued. Its goal is to honor the patient's preferences, optimize comfort, and allow a natural death when medical interventions, including maintenance of ventilatory support, are not achieving desired outcomes. If not done effectively, PE can cause unintended physical, emotional, psychosocial, or other stress for patients, families, and healthcare staff. Studies show that PE is done with much variability across the globe, and there is limited evidence of best practice. Nevertheless, the practice of PE increased during the coronavirus disease 2019 pandemic due to the surge of dying mechanically ventilated patients. Thus, the importance of effectively conducting a PE has never been more crucial. Some studies have provided guidelines for the process of PE. However, our goal is to provide a comprehensive review of issues to consider before, during, and after a PE. This paper highlights the core palliative skills of communication, planning, symptom assessment and management, and debriefing. Our aim is to better prepare healthcare workers to provide quality palliative care during PEs, most especially when facing future pandemics.

Inappropriate Dyspnea Management After Palliative Extubation (CS330)

Inappropriate Dyspnea Management After Palliative Extubation (CS330)

Using a Palliative Extubation Simulation-Based Learning Model to Teach Key Palliative Medicine Topics and Skills Across Graduate and Undergraduate Medical Education (Sch472)

Using a Palliative Extubation Simulation-Based Learning Model to Teach Key Palliative Medicine Topics and Skills Across Graduate and Undergraduate Medical Education (Sch472)

Abstract #1413762: Acute Mesenteric Ischemia: A Rare Presentation of Severe Hypothyroidism

Hypothyroidism has been associated with several gastrointestinal symptoms (GI) including constipation, ileus, atrophic gastritis, atony and dilation in various parts of the GI tract including myxedema megacolon. A more rarely reported association is ischemic colitis. We present a case of suspected mesenteric ischemia secondary to severe hypothyroidism. 65-year-old female with a history of oropharyngeal cancer treated with radiation therapy and Superior Mesenteric Artery syndrome with stent, presented with abdominal pain, nausea and vomiting for ten days. Imaging showed severe constipation with fluid-filled thick-walled small bowel loops. She was hemodynamically stable but with an elevated lactate (4 mmol/L) that improved with intravenous fluids. Overnight, she became disoriented, dyspneic and her abdominal pain worsened. She was upgraded to the ICU with suspected bowel ischemic. Her lactate was elevated but repeat CT was unchanged. Later, thyroid function tests were obtained showing an elevated TSH of 35.5 uIU/ml, low free T3 0.8 pg/ml and undetectable free T4. She was given a dose of intravenous levothyroxine that resulted in marked improvement in her abdominal pain and mental status by the next day. She was switched to oral levothyroxine. Over the course of her hospitalization, she developed staphylococcal bacteremia and later became obtunded requiring intubation. Over the subsequent days, she developed edema, hypothermia, bradycardia, and hypotension. Imaging showed bilateral pleural effusions, a new pericardial effusion, and ascites. She was diagnosed to be in myxedema coma and restarted on IV levothyroxine with high-dose steroids. After several days with minimal improvement in her condition, her family opted for palliative extubation. Hypothyroidism can result in decreased intestinal motility due to loss of gap junctions resulting in constipation and intestinal edema and can develop years after completion of radiation therapy as seen with our patient. We suspect that our patient’s symptoms were because of mechanical compression of the vascular supply of the small intestine due to severe dilation of the bowel wall as reported previously in cases of hypothyroidism-associated ischemic colitis. Given that the major focus was on the diagnosis of acute obstructive mesenteric ischemia, there was a delay in the diagnosis of severe hypothyroidism that later progressed to myxedema coma triggered by bacteremia. This case highlights the importance of checking thyroid function in patients with evidence of bowel dilation and ileus, since a delayed diagnosis of hypothyroidism can be fatal if left untreated.

End-of-life care in Brazilian Pediatric Intensive Care Units

ObjectiveMost deaths in Pediatric Intensive Care Units involve forgoing life-sustaining treatment. Such deaths required carefully planned end-of-life care built on compassion and focused on palliative care measures. This study aims to assess topics related to the end of life care in Brazilian pediatric intensive care units from the perspective of a multidisciplinary team. MethodThe authors used a tested questionnaire, utilizing Likert-style and open-ended questions. After ethics committee approval, it was sent by email from September to November/2019 to three Pediatric Intensive Care Units in the South and Southeast of Brazil. One unit was exclusively dedicated to oncology patients; the others were mixed units. ResultsFrom 144 surveys collected (23% response rate) 136 were analyzed, with 35% physicians, 30% nurses, 21% nurse technicians, and 14% physiotherapists responding. Overall, only 12% reported enough end-of-life care training and 40% reported never having had any, albeit this was not associated with the physician's confidence in forgoing life-sustaining treatment. Furthermore, 60% of physicians and 46% of other professionals were more comfortable with non-escalation than withdrawing therapies, even if this could prolong suffering. All physicians were uncomfortable with palliative extubation; 15% of all professionals have witnessed it. The oncologic team uniquely felt that “resistance from the teams of specialists” was the main barrier to end-of-life care implementation. ConclusionMost professionals felt unprepared to forego life-sustaining treatment. Even for terminally ill patients, withholding is preferred over the withdrawal of treatment. Socio-cultural barriers and the lack of adequate training may be contributing to insecurity in the care of terminally ill patients, diverging from practices in other countries.

Extubação paliativa: experiência de quatro casos em unidade de terapia intensiva neonatal

Objective: Characterize and describe neonatal patients with severe and irreversible conditions undergoing palliative extubation in a neonatal intensive care unit . Case description: Descriptive analysis of four cases of palliative extubation in a neonatal intensive care unit of a childrens hospital in the year 2019 to 2020 based on a review of electronic medical records of the following data: age, primary diagnosis, period of intubation, time of life between extubation and death, symptoms described in the time interval between extubation and death and comfort measures taken, family approach, diagnosis and previous or not follow-up with the palliative care team. All diseases into the exclusive palliative care classification. All patients died after the palliative extubation. The approach of the palliative care team was based on providing comfort measures for the patient, support for the family and the staff of the neonatal intensive care unit. Conclusion: The need for knowledge and deepening of the practice of palliative extubation is essential to make the end of life a time free of suffering, valuing respect and dignity for patients.

Extubação paliativa: experiência de quatro casos em unidade de terapia intensiva neonatal

OBJECTIVE: Characterize and describe neonatal patients with severe and irreversible conditions undergoing palliative extubation in a neonatal intensive care unit . CASE DESCRIPTION: Descriptive analysis of four cases of palliative extubation in a neonatal intensive care unit of a childrens hospital in the year 2019 to 2020 based on a review of electronic medical records of the following data: age, primary diagnosis, period of intubation, time of life between extubation and death, symptoms described in the time interval between extubation and death and comfort measures taken, family approach, diagnosis and previous or not follow-up with the palliative care team. All diseases into the exclusive palliative care classification. All patients died after the palliative extubation. The approach of the palliative care team was based on providing comfort measures for the patient, support for the family and the staff of the neonatal intensive care unit. CONCLUSION: The need for knowledge and deepening of the practice of palliative extubation is essential to make the end of life a time free of suffering, valuing respect and dignity for patients.

Palliative extubation experience in a community hospital in southern Brazil.

Palliative extubation experience in a community hospital in southern Brazil.

CASE REPORT OF RAPIDLY DECOMPENSATING PRIMARY PULMONARY CARCINOSARCOMA

CASE REPORT OF RAPIDLY DECOMPENSATING PRIMARY PULMONARY CARCINOSARCOMA

Limits of therapeutic intervention in a tertiary neonatal intensive care unit in patients with major congenital anomalies in Brazil.

Major congenital anomalies are an important cause of death in the neonatal intensive care unit (NICU). Therapeutic interventions and the suspension of those already in place often raise ethical dilemmas in neonatal care. We analysed treatments-such as ventilatory support, vasoactive drugs, antibiotics, sedation/or analgesia, central venous access and other invasive procedures-offered up to 48 h before death to all newborns with major congenital anomalies over a 3-year period in a NICU in Brazil. We also gathered information contained in medical records concerning conversations with the families and decisions to limit therapeutic interventions. We enrolled 74 newborns who were hospitalised from 1 January 2015 to 31 December 2017. A total of 81.1% had central venous access, 74.3% were on ventilatory support, 56.8% received antibiotics and 43.2% used some sedative/analgesic drugs in their final moments. Conversations were registered in medical records in 76% of cases, and 46% of the families chose therapeutic intervention limits. Those who chose to limit therapeutic interventions asked for less exposure to vasoactive drugs (P=0.003) and antibiotics (P=0.003), as well as fewer invasive procedures (P=0.046). There was no change in ventilatory support (P=0.66), and palliative extubation was not performed for any patient. The therapeutic intervention was mainly characterised by maintenance of the current treatment when a terminal situation was identified with no introduction of new treatments that could increase suffering. The families' approach proved to be essential for making difficult decisions in the NICU.

Palliative extubation: obstacles, challenges and solutions

Life support withdrawal can be a challenging decision, but it should be considered as an option when death is inevitable or recovery to an acceptable quality of life is not possible. The process is beset by obstacles that must be overcome to finally offer patients comfort and a peaceful death.In this article, we offer a series of tools that seek to solve the challenges of palliative extubation, as well as a protocol that could facilitate the decision to withdraw life support, making palliative extubation an alternative to consider instead of artificially prolonging life at the expense of unacceptable human and economic costs.

The Initial Impact of the Coronavirus Disease 2019 Pandemic on ICU Family Engagement: Lessons Learned From a Collaborative of 27 ICUs.

To describe the impact of coronavirus disease 2019 on family engagement among ICUs participating in a multicenter collaborative promoting implementation of family-centered care projects and to report sites' experiences with the collaborative itself prior to its cancelation due to the pandemic in March 2020. Cross-sectional survey. Twenty-seven academic and community ICUs in the United States and South Korea. Site leaders. Prior to March 2020, all sites had participated in 6 months of webinars, monthly calls, and listserv communication to facilitate projects and to collect preimplementation family satisfaction and clinician perception data. Planned projects included ICU orientation initiatives (12, 44.4%), structured family care conferences (6, 22.2%), and ICU diaries (5, 18.5%). After cancelation of the collaborative, 22 site leaders (81.5%) were surveyed by phone from June 2020 to July 2020. Twenty (90.1%) reported having stopped their site project; projects that continued were 1) a standardized palliative extubation protocol and 2) daily written clinical summaries for families. Sites described significant variability in visitor restriction policies and uncertainty regarding future policy changes. Four sites (18.2%) reported that their hospital did not provide personal protective equipment to visitors. Regarding video conferencing with families, 11 sites (52.4%) reported clinicians' using their own personal devices. Two-hundred twelve family surveys and 346 clinician surveys collected prior to cancelation highlighted a broad need for family support. When leaders were asked on a scale from 0 to 10 how helpful collaborative activities had been prior to cancelation, mean response was 8.0 (sd 2.5). While the collaborative model can help promote ICU family engagement initiatives, coronavirus disease 2019 has impeded implementation of these initiatives even among motivated units. ICUs need adequate personal protective equipment for visitors and video conferencing capabilities on hospital devices while strict visitor restrictions continue to evolve.

Invasive Beatmungstherapie im Sterbeprozess beenden – Schritt für Schritt

ZusammenfassungEine invasive mechanische Beatmung kann beendet werden durch sofortige (palliative) Extubation oder durch schrittweise Reduktion der Beatmung mit Belassen des Beatmungszugangs (terminales Weaning). Beide Verfahren sind ethisch gleichwertig und im Alltag durchführbar, sodass individuelle Patientenfaktoren und die Erfahrung des Behandlungsteams ausschlaggebend sind. Im Vordergrund steht immer das Ziel: Patient und Angehörige sollen nicht leiden.

Aspectos bioéticos de la extubación paliativa dentro de los cuidados de fin de vida en el paciente no recuperable en la UCI

Palliative, compassionate or terminal extubation are terms that are being included more and more frequently in hospital institutions and particularly in intensive care units (ICU). JustificationThe limited number of ICU beds in the world, the oldest age of the population and greater survival in acute disease, make there are more and more situations in those that require end-of-life decisions; in patients unable to make decisions and different positions in front of the artificial vital supports installed. Problem statementICUs that have not used palliative extubation within their strategies for reorienting the therapeutic effort or that they are initiating the culture of palliative sedation and end-of-life care, face the need for a review comprehensive subject matter and generate reflections on extubation due to compassion in the ICU. MethodologyLiterature review and analysis from a bioethical perspective. Results and discussionTerminal extubation appears as a strategy to avoid prolonging unnecessarily life in non-recoverable patients and as a measure to alleviate the suffering, in cases where there is no benefit from continuing invasive ventilatory support. The COVID-19 pandemic also generates another series of tensions to include, since it is necessary to avoid prolong life support in patients with unrecoverable conditions and who are no longer they benefit from being in the ICU due to the futility of the therapies; but it is known that the removal of the orotracheal tube creates a risk of aerosols, which can lead to increased exposure for the health personnel of the SARS-CoV-2 virus.

Abstract 14494: Once You 1c It, You Can’t Unsee It: A Case of Flecainide Toxicity

Introduction: Flecainide is a class 1c antiarrhythmic commonly used for the treatment of atrial and ventricular arrhythmias in the absence of underlying structural heart disease. The significant proarrhythmic effects of the drug warrant familiarity with the drug and its toxicity. Flecainide overdose, whether intentional or iatrogenic, is a life threatening emergency with mortality rates as high as 22.5%. We present a case of intentional flecainide overdose and its management. Case: A 78-year-old man with a history of heart failure, paroxysmal atrial fibrillation on flecainide, presented to a local ED after a suicide attempt. He was initially hemodynamically stable and a 12-lead EKG revealed a wide-QRS bradyarrhythmia (See figure 1). Electrolyte panel showed normal potassium and pH. During transport to our tertiary cardiac intensive care unit, the patient declined and was critically ill on arrival. The diagnosis of flecainide toxicity was suspected and therapy was initiated on arrival. Despite therapy with sodium bicarbonate and fat emulsion, the patient continued to decline. Renal replacement therapy was started and the patient was evaluated for mechanical circulatory support. Ultimately, the patient’s family elected for palliative extubation. The patient’s flecainide level returned more than four times above the therapeutic range. Discussion: This case highlights the importance of a high index of suspicion when faced with a wide-QRS arrythmia in a patient with suspected antiarrhythmic overdose. The persistence of these rhythms after correction of acid-base abnormalities and electrolyte derangements should prompt aggressive, empiric treatment of potential overdose. The presence of electromechanical dyssynchrony in this context is an ominous sign and should prompt simultaneous evaluation for biventricular mechanical circulatory support concomitant with medical therapy for suspected overdose. Figure 1