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Noninvasive ventilation for acute respiratory failure near the end of life*

Sinuff, Tasnim MD, PhD; Cook, Deborah J. MD, MSc; Keenan, Sean P. MD, MSc; Burns, Karen E. A. MD, MSc; Adhikari, Neill K. J. MDCM, MSc; Rocker, Graeme M. MHSc, DM, FRCP, FRCPC; Mehta, Sangeeta MD; Kacmarek, Robert PhD, RRT; Eva, Kevin PhD; Hill, Nicholas S. MD

doi: 10.1097/CCM.0B013E3181653584
Clinical Investigations
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Rationale: For patients with acute respiratory failure who have declined intubation and resuscitation or have chosen comfort measures only, noninvasive ventilation (NIV) may help them achieve important health or personal goals, or merely prolong the dying process.

Objective: To determine clinicians’ attitudes to and stated use of NIV for these patients.

Methods: We developed an instrument to assess the attitudes of intensivists, pulmonologists, and respiratory therapists (RTs) toward the use of NIV for patients with acute respiratory failure near or at the end of life. After assessing its psychometric properties, we mailed the survey to these clinicians at 18 Canadian and two U.S. hospitals. We analyzed factors associated with stated use of NIV for do-not-resuscitate and comfort-measures-only patients.

Results: Overall, 104 of 183 (57%) physicians and 290 of 473 (61%) RTs participated. Two thirds of physicians include NIV during life support discussions with do-not-resuscitate patients at least sometimes, and 87% of RTs stated that NIV should be included in such discussions. For patients choosing comfort measures only, almost half of physicians reported including NIV as an option in their discussions at least sometimes, while fewer than half of RTs stated that these discussions should be conducted. Most (>80%) physicians use NIV and most (>80%) RTs are asked to initiate NIV for do-not-resuscitate patients with chronic obstructive pulmonary disease or cardiogenic pulmonary edema. Fewer clinicians report using NIV for do-not-resuscitate patients with underlying malignancy (59% of physicians, 69% of RTs) or for patients choosing comfort measures only (40% of physicians, 51% of RTs; p < .001).

Conclusions: For patients with do-not-resuscitate orders, many physicians use NIV, and many RTs are asked to initiate NIV, most often to treat chronic obstructive pulmonary disease and cardiogenic pulmonary edema. Further study is needed on the goals of NIV near the end of life, whether these goals are understood by all stakeholders, and how well they are achieved in practice.

From the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre (TS, NKJA), Department of Critical Care and the Li Ka Shing Knowledge Institute, St. Michael’s Hospital (KEAB), Department of Medicine, Mount Sinai Hospital (SM), and the Keenan Research Centre (KEAB) and Interdepartmental Division of Critical Care Medicine (TS, KEAB, NKJA, SM), University of Toronto, Toronto, Ontario, Canada; Departments of Medicine (DJC) and Clinical Epidemiology and Biostatistics (DJC, KE), McMaster University, Hamilton, Ontario, Canada; University of British Columbia, Vancouver, British Columbia, Canada (SPK); Divisions of Respirology and Palliative Medicine, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada (GMR); Department of Anesthesiology, Harvard Medical School, and Department of Respiratory Care, Massachusetts General Hospital, Boston, MA (RK); and the Division of Pulmonary Critical Care and Sleep Medicine, Tufts University School of Medicine, Tufts-New England Medical Center, Boston, MA (NSH).

Drs. Burns and Sinuff receive salary support from the Canadian Institutes for Health (CIHR) Research Clinician Scientist Awards. Dr. Cook is a research chair for CIHR.

Supported, in part, by Hamilton Health Sciences New Investigator Fund, Ontario Thoracic Society block term grant.

Dr. Eva has received research grants and honoraria for speaking from Respironics, Puritan Bennett, Maque, Viasys, and Hamilton Medical. Dr. Hill has received research grants and honoraria and consulted for Respironics and ResMed. No other author has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

For information regarding this article, E-mail: taz.sinuff@sunnybrook.ca

© 2008 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins