These are some very well thought out and supported responses. If it is to the point of comfort care then I have to agree then what is the goal/point? If the issue is dyspnea, there are much better means to attenuate this in the patient's final days and hours than NIV. This brings to mind another question that I have struggled with for years, does DNR/DNI equal decrease agressiveness of care? Should it or shouldn't it? I will start another thread and appreciate your reflections.
This is a debate that could go on forever, becasue for every example of the inappropriate application of NIV- someone can provide a story to support the reverse.
For example: I once had a muscular dystrophy patient who was in the final stages of his disease. He first presented in October with pneumonia and was intubated. Afer the first week, the physicains were ready to trach him. I recommended NPPV. The patient came off the ventilator, his pneumonia resolved and went back home and was weaned to NIV for nocturnal support. Over the next two months, Tony's cardiac and respiratory status deteriorated. But he was still able to participate in his brothers wedding, see a niece be born, spend one last Thanksgiving, Christmas and New Years with his family. In January, he was readmitted to the hospital and required continuous ventilator support, provided by NPPV. After his first cardiac arrest, it was apparent that he would not be going home and his status was changed to DNR. However, we continued to support to his respirations until the family could make arrangements to get his brother home from Dessert Storm. At which, time NPPV was discontinued and Tony died. The application of NPPV for this patient, gave the patient some valuable and quality time with family. He was able to communicate with his family and friends up till the very end. He more than once personally thanked me for the intervention I made on his behalf. And to this day, I receive Christmas Cards from his family.
The bottom line is each patient needs to be looked at as an individual. All the contributing factors need to be accounted for and communication with the patient and family is key. And this communication needs to take place, prior to the crisis situation.
This example wasn't one of a DNR/DNI/Comfort Care patient being placed on NIV. Given all the patient went through, the apparent goals for survival as long as possible, I have to wonder if having a trache (and using Passy Muir Valve for communication, or perhaps tracheal oxygen insufflation ala Cadence Respironics product if available) and using a portable ventilator might have allowed better secretion clearance, prolonged his life better, allowed the same traveling and going to events, etc., as opposed to limping along on Bipap. Was the arrest related to a respiratory deterioration of event?
It sounds like even at the end of his life he never opted for comfort care, that this patient's case has nothing to do with the topic of using NIV on patients whom have opted for comfort care.
And the topic changes a bit if one is dealing with patients in whom the primary or exclusive cause of their illness is impairment of ventilation. Imagine we had a repeat of the polio epidemic and had very young patients whom would only survive on ventilators---no doubt they would't be made DNR/DNI but would be kept alive quite easily with modern ventilators. (Spinal Injury Units also). If some other disease impacted such that a DNR/DNI status was decided upon the ventilatory support would already be in place and withdrawal would be a different issue than slapping Bipap on a patient whom is DNR/DNI/Comfort Care and dying of end stage cancer with sudden respiratory deterioration.
In some patients whom are DNR/DNI NIV might be a very viable thing to do or try. A COPDer patient whom is DNR/DNI arrives in the ER with an excacerbation. They are placed on NIV and turn around in a few hours,relieving the ventilatory load, oxygen, bronchodilaors, antibiotics, steroids, in some combination do their "magic". But placing any DNR/DNI patient on NIV then places a big responsibility on us (medical professionals as a whole) to not let the imposition of NIV be a way to bury our heads in the sand if/when the patient doesn't turn around, continues to slide downward, etc.
At any point in time I'd be willing to bet that in at least 80% of the patients whom are both DRN/DNI and on NIV, that it's leading more to a bad death than to any good life.
I am glad to know that there is discussion of this topic. My frustration involves a very elderly patient that at one point made herself an out of hospital DNR which we transferred to in hospital. She was admitted with a severe ischemic stroke paralyizing her one side of her body and leaving her unable to communicate. She had come from a nursing home and had many preexisting medical problems. She was noted to have abdominal breathing on admission and on day 2 her heart rate and resp. rate increased with labored breathing and the patient was placed on bipap. I took care of her the preceding day. Without the bipap the patient would quickly desat. So now it is considered life staining and a withdrawal of life support would have to be done to allow the patient to come off of the machine. Her face was reddened and swollen due to the mask. The family is very receptive but not aware of medical situations. I feel we have given them a "blanket" and it needs to be taken away. Its really not fair that we have left them with that decision. I feel we should have left the natural process of death occur and not prolonged the patients suffering.
This is a pretty classic example of how Bipap (NIV) is being routinely and systematically used in a very detrimental way to thousands of patients across the country.
Just look at the absurdity and idiocy of how this patient is/was managed.
Elderyly patient. Living in a nursing home with many pre existing medical problems.
Makes a decision to be DNR (maybe not DNI?, but still..)
Now suffers a severe ischemic stroke which paralyzes her.
Now sure DNR doesn't mean not to intubate, or a strict exclusion never to use Bipap. But I'll just bet that the option of Comfort Care wasn't offered, much less encouraged as a VERY viable way to carry out the inherent intent of a DNR order.
NO let's just all bury our heads in the sand and slap Bipap on these patients. Then, as you described, the face reddens from the mask, pressures "have to be" increased. Then any decision to remove the Bipap is linked more directly to the patient's demise. How nice of us to to use that family decision to dump a boatload of guilt in their lap.
Death can rarely be natural once the patient is in the hospital--that line has already been crossed and the patient can't just go climb on an ice berg and float away. But that doesn't mean it has to be some sick parody and a last gasp at honoring whatever devices we can still slap on the patient short of a full code (I'm waiting for someone to invest a very effective non invasive Left Ventricular Assist Device so this stupid show can get even more twisted).
But just because death isn't natural, we should use Palliative Care Medicine to alleviate the suffering. Natural Shmatural, we have tools to alleviate suffering during end of life care. Bipap isn't one of them, but is used now to usher in so many "bad deaths".
Palliative care on the intensive care unit
J.F. Cosgrovea, , , I.D. Nesbitta and C. Bartleyb
aFreeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
bQueen Elizabeth Hospital, Gateshead, NE9 6SX, UK
Available online 10 October 2006.
When futility of ongoing active treatments has become apparent in critically ill patients, effective palliative care must be instituted. Such care includes relief from the physical, emotional and spiritual aspects of dying. Five domains have been described; they are adequate pain and symptom relief, avoidance of inappropriate prolongation of dying, achieving a sense of control, having burdens relieved and strengthening relationships with loved ones. The mainstay of such care is frequently effective analgesia. Other physical provisions include sedation, temperature control, anti-emesis, reassurance (if conscious) and good basic care e.g. oral toilet, wound care, pressure area care, cleaning of soiled areas. Cultural and religious aspects must also be considered. Once analgesia and sedation are effective any intervention not advancing patients' goals (i.e. ˜to have a good death') should be eliminated. Critical care staff should also provide for the patient's family and have an understanding of the legalities of death e.g. certification, coroner, etc. and medico-legal examples of conflict. Senior clinicians therefore have a pivotal role in guiding an individual's care, minimizing conflict and educating others in both the practicalities of effective palliative care and the controversies surrounding the subject e.g. Doctrine of Double Effect and Euthanasia. "
Gee, seems to me that "avoidance of inappropriate prolongation of dying" means that we don't respond to the dying process by slapping Bipap on a patient.