ARTICLE REVIEWS BEST PRACTICES IN VENTILATOR REMOVAL OF ICU PATIENTS

    The current issue of Supportive Voice, at www.supportivecarecoalition.org, features an article on best practices used by palliative care teams when removing mechanical ventilation from ICU patients.  The authors say that many ICU physicians and nurses are reluctant to remove ventilators, given the ICU’s focus on using aggressive measures.  EOL ventilator removal attitudes and practices vary, as does information in journal articles that give the best ways to address the issue.

    The authors are a group of palliative care advanced practice nurses (APNs), from several hospitals in the Kansas City area, who initially held monthly meetings to support each other in their work.  After they shared their own practices and identified similarities in different settings, they set a goal to analyze the best practices for ventilator removal at four area hospitals.  Other objectives of the project included “identifying roadblocks and successes in providing palliative care in the ICU, identifying commonalities/differences in practices, as well as identifying areas in palliative care for future research.”  Each of the participating hospitals had palliative care teams (PCTs) in place, and each of the teams acted as an advocate “for the patient/family’s goals of care.”

     The researchers identified three major factors which influenced a decision to withdraw ventilation:

• Previously expressed wishes by the patient, either verbal or written;
• A poor prognosis, in the judgment of the medical team; and
• “Determination that the current quality of life would be unacceptable to the patient.”

     In most cases, the PCTs were active and present when ventilation was removed, unless it was scheduled at a time when the team was not available.  “The ICU staff was actively involved in the plan of care,” and this “provided significant support for both the families and the staff.”

     Roadblocks to an “easy” removal process were:  1) Conflicts between the physician and family about goals of care; 2) “Last breath” referrals, which gave the palliative care teams no time to develop a relationship with the family, and 3) Patients who had no family advocates.

     The best practices identified by the researchers that all the teams consistently applied were:

• Skillful communication;
• Respect for patient and family “goals, preferences, and choices”;
• Acknowledgement of the needs of families in making end-of-life decisions;
• Giving comprehensive care;
• Using the strengths of the members of the interdisciplinary teams; and
• “Providing ongoing palliative care education in the acute care setting.”

     The authors conclude by saying, “The original intention of this group of palliative care APNs – to champion one another in our work and to provide support, professionally and emotionally – has in itself been a valued outcome.”  The complete article is available online at http://www.supportivecarecoalition.org/NR/rdonlyres/2FCDA1E6-DC40-4F5D-ABFE-EE78900C278B/0/SVSummer07FINALWEB.pdf.  (Supportive Voice, Summer/07)