We seem to run into this problem quite frequently about residents(teaching facility) ordering BiPAP on these patients against our recommendation...their reason...to assist their breathing(agonal). Even after everything else has been D/C including OG, antibiotics, treatment, etc...
I understand indications/contra for BiPAP including protecting airway, alert, responsive, but it's like they are(residents) trying to ease discomfort for the family(at the bedside) when we're setting it up.
What's your opinion and does anyone else out there run into this same problem?

Could someone please help me out here and point me in the right direction with national guidelines and/or ethics behind this to support our judgement not to use BiPAP in this patient population.

Thanks, Wade

I had the same trouble in my hospital up until about 2 years ago. I took a policy to Med Executive meeting that said that all BiPAP for anything other than sleep apnea must be used in either the ICU or the Stepdown unit. the residents don't want to transfer DNR/DNI patients to ICU or Stepdown. We have had them try and say it is for sleep apnea in an attempt to fool the policy but we draw an ABG and that is the deciding factor.

Wade,
I would tell you to talk to your hospitals ethicist. They should be able to help you if the physician is unwilling to listen to sound MEDICAL advice.

My opinion is that BIPAP is mechanical ventilation and should not be done on these patients unless you are trying to get them to hang on untill family arrives. With BiPAP you are just prolonging pain and we should not be doing this if everything else is stoped and the patient is terminal.

OKRT,
We are actually in the process of creating a NPPV protocol and I have mentioned this topic to be included.

Light,
That's a great idea. I know we have an ethics committee...I will see what I have to do to present it to them.

Thanks,
Wade

Go to www.rtmagazine.com go to Archives and find the August 2006 issue. Paul Nuccio and I did a Point/Counterpoint (no I didn't get to say "Paul you ignorant little slut" ala SNL) on this issue. The title I wrote for was supposed to be "NPPV does/does not have a postive role to play in DNR/DNI patients WHOM HAVE OPTED FOR PALLIATIVE OR COMFORT CARE. But the capitalized part was removed. I think that on occasion and with trepidation, NPPV can be used on DNR/DNI patients if not comfort care---i.e. COPDer in crisis in ER whom can be turned around quickly. But in this case also one has to keep an eye on how far out on a limb we're going.

Then when they put DNR/DNI patients on life support up on a floor ward on NPPV with settings maxed out and all.......what a big recipe for "medical error".

Go to www.rtmagazine.com and Archives August 2006 issue. There is a Pro/Con debate there between myself and Paul Nuccio.

Thank you Jeff!

There was a recent article in Critical Care Medicine (Jan 2007) that address the use of NPPV in DNI/DNR patients. These guidelines were compiled by some of the top NIV experts and provides some valuable information. You may even want to share it with some of your physicians and other RT members. The article basically states that NPPV is acceptable in DNI/DNR patients- but when dealing with DNR patients, it should be discussed with family/patient and allow them to make the decision on wether or not to use NPPV as a comfort measure. Attached is the abstract.

Noninvasive positive pressure ventilation in critical and palliative care settings: Understanding the goals of therapy *.
Review Article
Critical Care Medicine. 35(3):932-939, March 2007.
Society of Critical Care Medicine Palliative Noninvasive Positive Pressure Ventilation Task Force
Abstract:
Objective: Although noninvasive positive pressure ventilation (NPPV) is a widely accepted treatment for some patients with acute respiratory failure, the use of NPPV in patients who have decided to forego endotracheal intubation is controversial. Therefore, the Society of Critical Care Medicine charged this Task Force with developing an approach for considering use of NPPV for patients who choose to forego endotracheal intubation.
Data Sources and Methods: The Task Force met in person once, by conference call twice, and wrote this document during six subsequent months. We reviewed English-language literature on NPPV for acute respiratory failure.
Synthesis and Overview: The use of NPPV for patients with acute respiratory failure can be classified into three categories: 1) NPPV as life support with no preset limitations on life-sustaining treatments, 2) NPPV as life support when patients and families have decided to forego endotracheal intubation, and 3) NPPV as a palliative measure when patients and families have chosen to forego all life support, receiving comfort measures only. For each category, we reviewed the rationale and evidence for NPPV, key points to communicate to patients and families, determinants of success and failure, appropriate healthcare settings, and alternative approaches if NPPV fails to achieve the original goals.
Conclusions: This Task Force suggests an approach to use of NPPV for patients and families who choose to forego endotracheal intubation. NPPV should be applied after careful discussion of the goals of care, with explicit parameters for success and failure, by experienced personnel, and in appropriate healthcare settings. Future studies are needed to evaluate the clinical outcomes of using NPPV for patients who choose to forego endotracheal intubation and to examine the perspectives of patients, families, and clinicians on use of NPPV in these contexts.

Wade,
I can also provide you with several other articles that discuss the use of NPPV in palliative care. Just let me know if you need them. However, I think the January article in Critical Care Medicine does summarize them well.

So a patient is DNR/DNI, their disease has advanced to the point where COMFORT care is the only reasonable goal....why the flake would any sane person then advocate strapping a mask for NIV on such a patient.

That Consensus Statement in CCM had to be such I suppose.

But also from that same article.

"Adverse consequences may be serious, including unmet or conflicting expectations, avoidable adverse outcomes associated with NPPV, inappropriate use of medical resources, inadvertent prolongation of the dying process, and intensification of patient suffering and family duress."

Duh.

It's one thing if a COPDer whom is DNR/DNI arrives in the ER and one can "turn them around" with a few hours of Bipap. It's quite another thing when a person whom is clearly dying, has opted for DNR/DNI, and then has their care defined as "comfort" is placed on NIV. I used to work at a hospital which had a whole unit devoted to Palliative Care, they trained Palliative Care Fellows (real MD's specializing in Palliative Care). NOT ONCE was there ever an order for us to come over there and put anyone on NIV.

But back to the CCM article...Look at how it's discussed as regards slapping NIV on a DNR/DNI patient whom is now comfort care (3rd Category in article)..

"Category 3: NPPV as a Comfort Measure for Patients Who Decline Endotracheal Intubation TOP
Scenario 3.
A similar 68-yr-old man with severe oxygen-dependent COPD presents with an acute exacerbation of his COPD. Careful discussion with him reveals that this patient has a baseline quality of life that he finds unacceptable; before this exacerbation, he was unable to walk across his living room without stopping because of dyspnea. He reports being very distressed at the slow progressive decline in his functional capacity and his severe, limiting symptoms, despite maximal outpatient therapy. The patient wishes to be kept comfortable. His preferences are clear; he does not want any form of life-prolonging therapy. He and his partner understand the consequences of this decision. His partner is sad at the prospect of losing her husband but wants to ensure that his treatment preferences are honored. The patient has been on NPPV in the past, and she asks whether NPPV might be attempted to help relieve his breathlessness so that he and his partner can communicate with one another.

Discussion.
Patients in the third category, especially those with a terminal disease (such as an underlying malignancy) or at the final stage of a chronically progressive disease (such as COPD, chronic heart failure, or neuromuscular disease), may decide that they do not wish life-prolonging therapy and choose comfort measures only. In this setting, it is conceivable that NPPV might be used as a form of palliative care, to attempt to reduce the dyspnea. Furthermore, although most patients and families are interested in ensuring comfort while dying, some are also interested in maintaining cognition and the ability to communicate (17). NPPV in this circumstance would only be considered successful if it improves the patient's symptoms of dyspnea or other distress without causing other troubling consequences. Patients in this category should not be encouraged to tolerate discomfort associated with NPPV because the primary goal of the therapy is patient comfort. NPPV should be discontinued if patients feel that the NPPV is not making them more comfortable. Furthermore, when used in this context, there is no justification for providing NPPV to patients who are unable to communicate about whether NPPV has improved their symptoms.

It is important to acknowledge that some patients or family members who choose comfort measures only may still maintain a desire or hope for a cure or a miracle and that this may reflect ambivalence toward life-sustaining treatments. Discussing such ambivalence can provide an opportunity to explore patients' and families' concerns and fears about end-of-life care, but the existence of this ambivalence does not necessarily require life-sustaining therapies that are not indicated or for which the burden outweighs the benefit (18). However, a patient who has chosen not to undergo endotracheal intubation and is using NPPV, hoping it will even briefly prolong life, should be considered as category 2 rather than 3. It is also important that the goals of care be continually reassessed, as risks, benefits, and treatment preferences can change over time, and therefore, the goals of care and the category of NPPV may change over time.

Some patients who do not want prolonged life-sustaining therapy may choose to undergo a time-limited trial of NPPV to achieve the goal of surviving until the arrival of family members or friends traveling to visit the patient. Although these patients may have a terminal illness and may be actively dying, this use of NPPV would be an example of a category 2 rationale. In this situation, NPPV would be used to provide life support, delaying death until the family member arrives to say goodbye, providing that the benefits of NPPV outweigh the burdens from the patient's perspective."


First it amazes me how this "let's use NIV until the distant relative can arrive" is always used! I almost want to start playing the violin in the background! The last time I witnessed such an idiotic rationale by the time the family member arrived the patient on NIV had such high settings that any "decision" to remove the NIV was tantamount to deciding when he would succumb (with guilt now nicely dumped on family).

"Hi Nephew Bill, now that you've arrived I'm coming off this IPAP 20 EPAP 14 and FIO2 1.0"

The clinical scenario for the 3rd category describes a COPD patient whom is DNR/DNI/Comfort Care whom is familiar with Bipap and is already SOB. The only sensible thing to do IMO is to use pharmacologic agents to relieve the dyspnea, perhaps using NIV ONLY as one gets those ducks in order-_not as THE "treatmetn" for dyspnea. Most of the patients I have seen whom are DNR/DNI/Comfort Care and then ordered on NIV have cancer and other diseases.

Why strap a NIV mask and device to these patients? What is the endpoint? The nurses and MD's then hold off on morphine as somehow the goal is now percieved to be survival, ABG's get ordered, settings get increased. I've even seen such patients in the ICU get threatened that "if you keep pulling the mask off we'll have to stick a tube down your throat".

I suspect many still view giving palliative levels of morphine as being euthenasia. Perhaps this whole debate has more to do with abortion and Terry Schiavo than with any real discussion of effective or compassionate Palliative Care.

The CCM article clearly states that no evidence is available for use in such Category 3 patients.

Again from the study...

"To date, no studies have fully assessed the effectiveness and safety of NPPV specifically in patients who are in category 3, even though NPPV may reduce symptoms of dyspnea in a broader group of patients with ARF from COPD (23, 24), in patients with advanced cancer and respiratory failure (30), and in selected patients with stable chronic respiratory failure from COPD (31). However, further research is needed to determine whether patients in category 3 benefit from NPPV. It is important to highlight that not only do we have inadequate clinical research on benefit in this unique category 3 setting compared with standard therapy without NPPV, but also on the potential harm. For example, many dying patients might find NPPV undesirable because the potential for relief of dyspnea is outweighed by discomfort due to the need for a tight-fitting face mask. The potential theoretical advantages could also be countered by a stressful fixation on technology at the end of life and limited ability to communicate imposed by the face mask. Moreover, there are no studies comparing NPPV in this setting with pharmacologic therapies such as morphine. Further research is needed before this approach can be considered a standard of care.

Nonetheless, it is theoretically possible that NPPV could be used in the setting of comfort measures only as an adjunct to opiates and nonpharmacologic therapies in a way that might minimize some side effects of opiates, such as decreased level of consciousness. However, it is important to emphasize that there is no convincing evidence that NPPV will diminish the burden of symptoms in patients who choose comfort measures only. For occasional patients, however, the relief of dyspnea and the improved level of consciousness might allow for more effective communication, especially during periods when NPPV is temporarily stopped. Hence, NPPV may offer symptom palliation for patients who are in this category and offer families an opportunity to communicate with patients who are close to the end of life. Importantly, the patient can and must maintain control over the decision to continue support. If discomfort exceeds benefit, the patient can simply choose to discontinue NPPV, and comfort should be achieved quickly with pharmacologic therapies. This may require anticipatory dosing of opioids to achieve patient comfort, as is sometimes necessary during withdrawal of invasive mechanical ventilation (32). If the patient becomes unable to communicate, the benefits of NPPV in this setting will likely have ceased, and therefore, NPPV should be stopped."

OK I leave it to you the RT's out there. You see these patients whom are DNR/DNI/Comfort Care (or in whom Comfort Care is clearly the ONLY valid clinical goal) and then placed on NIV. Is it a good thing? Are we doing them or their families any favor as we bury our heads in the sand with NIV? Do we not then use NIV as some kind of "magical illusion" that death isn't what's happening?