Recently, studies focused on the use of palliative noninvasive ventilation have provided descriptive data, new evidence, and qualitative appraisals of palliative NIV.
A prospective cohort study by Azoulay et al.9 reported outcomes of patients undergoing NIV in the context of “do-not-intubate” (DNI) orders (ie, category 2). A DNI order is present in about 20% of all patients receiving NIV in intensive care units (ICUs). A substantial hospital survival of 56% was observed, which was most obvious in the COPD patient subgroup. Importantly, for those who survived up to 90 days, health-related quality of life did not significantly change compared to baseline. Moreover, anxiety, depression, and posttraumatic stress disorder (PTSD)-related symptoms in patients and their families were similar to those seen when NIV was used in category 1 (full code) patients. These recent data, together with previously published reports,10,11 thus support the use of NIV in this clinical context.
A study by Nava et al.12 that focused on patients with end-stage cancer (ie, category 3 patients) assessed the acceptability and effectiveness of NIV versus oxygen therapy in decreasing dyspnea and its effect on the use of opioids. The study showed that NIV is faster and more effective compared to oxygen in reducing dyspnea and offers the potential to reduce the dose of opioids. Hospital mortality was similar in both groups. NIV was well accepted and well tolerated, again, with the best response in cases of hypercapnic respiratory insufficiency.
Finally, NIV has been evaluated in patients suffering from terminal phase motor neuron disease who are at the end-of-life. A qualitative study by Baxter et al.13 revealed important variations in patient wishes regarding the use of NIV toward the end-of-life and also a degree of uncertainty concerning NIV management among healthcare teams. Nevertheless, end-of-life use of NIV was generally perceived as beneficial, allowing a more peaceful end-of-life, free of choking or struggling to breathe during the final moments.
Even if current research findings support the use of noninvasive ventilation in palliative situations (categories 2 and 3 of the conceptual framework), important questions/objections have been raised, concerning possible discomfort and unnecessary prolongation of the terminal phase of life.14,15 Some aspects of the current controversies are summarized in Table 85–1.
Table 85–1Expected benefits and possible risks of end-of-life NIV: factors to be considered before NIV initiation (on an individual basis). ||Download (.pdf) Table 85–1Expected benefits and possible risks of end-of-life NIV: factors to be considered before NIV initiation (on an individual basis).
|Expected Benefits ||Possible Risks |
|Prompt relief of respiratory distress ||Discomfort from tight-fitting mask (facial necrosis) |
|Maintained cognition ||Noise exposure (up to 65 dB) |
|Time to finalize personal affairs (strategy to “buy time”) ||Possible unnecessary prolongation of the terminal phase of life |
|Dose of opioids diminished (with fewer or reduced opioid side effects) ||Nasal/oral dryness, nasal congestion |
|Improved ability to communicate due to diminished use of opioids and higher level of consciousness ||Limited ability to communicate imposed by the face mask |
|Reassurance, reduced end-of-life anxiety ||Stressful fixation on technology at the end-of-life |
|Say goodbye to loved-ones || |
Symptoms of PTSD in family members
Complicated grief 15