Comfort at End of Life

Findings may help reduce distress associated with ventilator withdrawal in critically ill patients

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This article is part of Harvard Medical School’s continuing coverage of medicine, biomedical research, medical education and policy related to the SARS-CoV-2 pandemic and the disease COVID-19.

On average, nearly one in five hospitalized Americans die in an intensive care unit each year, and many of these deaths occur after the decision has been made to extubate and move from curative- to comfort-focused care.

Although numerous professional societies and patient groups have advocated for improved management of ventilated ICU patients transitioning to palliative care, the process of palliative ventilator withdrawal (PVW) and the subsequent discomfort that patients experience has remained understudied. As a result, the practice varies widely across ICUs, and little is known about the indicators of patient distress and how to better control symptoms.

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Now, researchers at Harvard Medical School and Hebrew SeniorLife report on a study, published in Chest, of the PVW procedure performed in intensive care units at end of life. The study’s goal was to determine the level of distress patients experience and identify treatments that could bring relief.

Findings show that up to one-third of PVW patients experience an episode of rapid breathing, called tachypnea, as a marker of distress, and administration of opiates before PVW could help with symptom control. Corey Fehnel, HMS assistant professor of neurology at Beth Israel Deaconess and a palliative care researcher in the Hinda and Arthur Marcus Institute for Aging Research at Hebrew SeniorLife, is lead author on the paper.

Monitoring symptoms of distress among hospitalized COVID-19 patients at end of life presents even more of a challenge. COVID-19 patients who are intubated on mechanical ventilation require providers to observe special aerosolized droplet isolation precautions. They must wear N95 masks, face shields, hats, gowns and run HEPA filters in the room when opening the circuit to the ventilator or performing procedures, including extubation. These precautions make it difficult for critically ill patients to use nonverbal cues as a means of communication with their care providers.

In addition, patients are physically isolated with similar patients, and providers try to limit the number of times they enter the patient's room to prevent transmission of the virus. But most importantly, families are not allowed in the hospital to be with these patients during extubation, and their support is an important part of easing patient distress and assuring patient comfort at end of life. Taken together, the combined effect is a perfect storm of barriers to effective symptom assessment for these patients.

“We fervently hope that all patients will be comfortable at end of life in the ICU but unfortunately some people experience discomfort, and we identified one tactic to alleviate that distress,” said Fehnel. “The results of this study, which point to administration of opiates before PVW and in anticipation of distress, could help with symptom control and can be readily applied to COVID-19 and all critically ill patients during this time of great need.”

This research is supported by grant support from the National Institute on Aging (K23AG066929 and R03AG060186).

Adapted from a Hebrew SeniorLife news story.