When patients opt for comfort care, that is what we should offer them, not an artificial prolongation of life

Right now, somewhere in some hospital, a DNR/DNI patient, one who has opted for comfort care, is being placed on NPPV (noninvasive positive pressure ventilation). What is the likely situation in which this is happening? Is NPPV application likely to be an integral part of fulfilling the patient’s wishes—that he or she be allowed to exit this world with as little suffering as possible? Or, when it is all over, was the application of NPPV instrumental in ushering in a bad death?

The State of End-of-Life Care
End-of-life care in the United States is already deficient enough without adding the abomination of NPPV to the mix. Numerous studies and reports clearly show that end-of-life care is rather abysmal.^1-11 From communication to patient perceptions, from pain management to formal training of clinicians in end-of-life issues, so much needs to be improved. Is there any reason to think that the introduction of noninvasive ventilation is positively impacting or miraculously changing the current situation? Might not instead it be more likely that the inappropriate “offering” or imposition of NPPV is being utilized as an enabling tool for clinicians, family members, even the dying patients themselves to not confront, at some important and rather urgent level, that dying is what is occurring?

In addition to the standard recognized problems in end-of-life care that bear consideration for this discussion, several other issues merit mentioning—as they too have relevance for the application of NPPV in such patients.

For one, there is the myth of “patient autonomy.”^12,13 Actual patient autonomy is a valid, if at times somewhat elusive, goal. But consider the customary reality of the mental and physical condition of the patient as life is ending, as well as the incredible amount of technical and statistical information that would have to be imparted for someone to truly make an informed and autonomous decision. Do not most patients look with trust to their physicians for guidance? When we advocate the “offering” of NPPV to DNR/DNI patients who have opted for comfort care, it behooves us to honestly and soberly confront the realities of any patient autonomy as well as the true relative power and knowledge status of the patient/clinician relationship. When a DNR/CC patient is offered and “agrees” to NPPV, is that really reflective of patient autonomy? Or is it more often reflective of them being led down the path of our own denial?

Another issue is the way that continuing to attempt curative goals under futile conditions reduces the practice of medicine to the art of practicing magic—the creation of illusions.¹⁴ Usually, when the decision for comfort care is chosen, patients have already accepted the futility of fighting their disease processes and have put their trust in our professional ability to ensure that comfort care truly happens. For us to now switch gears, resort to magic while pulling the NPPV rabbit out of our hat—how dare we do such a thing? Is not then the offering or imposition of NPPV just one last tragic magic act: We create the illusion that death is not happening as the mask is strapped on the face; but, unlike professional magicians, we, too, become fooled by our own magic act, believing we do not have to face the demise of the patient. And indeed we often don’t—provided our shift ends in time.

Every time this issue comes up, it seems someone brings up the scenario that NPPV could be used so that some distant relative can make it to the hospital in order to say a last good-bye to the dying patient. Sure, this is possible. I have seen NPPV be used or justified for this reason only one time, and by the time the family member finally did arrive, it was then “problematic” to just summarily remove the NPPV device. The pressure settings and Fio₂ were then at the end of the scale. What was to be done then? Does the NPPV just come off, morphine drip go up, 'a la a magician removing the table linen without the dishes crashing to the floor? More likely, any such removal of NPPV, coupled with a rapid increase in morphine to palliate the resultant dyspnea, would make any resultant demise look like active euthanasia.

In that situation, where NPPV was initially set up to facilitate such a last good-bye, the device instead ended up staying on the patient for days and days. It became another in a long line of clinical fiascos I have witnessed wherein NPPV was used on a DNR/DNI patient.

The other postulated reason for using NPPV on these patients is so “they can get their affairs in order.” Affairs in order? The patient has a terminal disease. They have chosen comfort care, and they are entering the dying phase. Are we to then put them on NPPV so they can continue to check their e-mail and do online banking, or perhaps complete a patient satisfaction survey?

As Tanvetyanon writes,¹⁵ “Perhaps, patients who wish to finalize their affairs should be advised that at this time in their lives, there are no more burdens to bear, no more affairs to finalize, no more fights to pursue. Let them know that the most important thing is to be at peace with themselves. Also, the myth about morphine should be dispelled: low-dose morphine to relieve breathlessness will not cause excessive drowsiness—it will allow interaction with family members.”

Personal Feelings Get in the Way
I suspect these conjured rationales for NPPV all have far more to say about our own personal inability to accept death and our lack of knowledge and skill in end-of-life care than it really has to do with any justifiable use of NPPV in these circumstances. I worked for 3 years at a hospital that had an actual palliative care unit, one staffed by actual palliative care physicians. Not once was there ever a request for NPPV in that unit.

Before we had NPPV available, the onset of respiratory failure was often a “line in the sand,” which, when crossed, meant that true pharmacologic palliation was undertaken, as it was our only option other than reversing the DNI/DNR order. Now that line in the sand is blurred whenever NPPV is applied. Does not even the offering of NPPV confer some expectant legitimacy or somehow imply that the patient should avail themselves of our “magic”? If a DNR/DNI patient arrives in the emergency department (ED) suffering from respiratory failure secondary to chronic obstructive pulmonary disease (COPD) or pulmonary edema, entertaining a certain amount of NPPV might certainly be justified. But in these patients, also, we must be aware of the slippery slope and not allow NPPV to blur that line in the sand. Indeed, one study¹⁶ showed that even in these patients the application of NPPV ensures that they will become a revolving door patient as “the majority of the patients will die or develop another life-threatening event within 1 year.”

What the Studies Show
There are studies purporting to show that NPPV is a viable option in DNR/DNI patients.^17,18 But in these studies only two patients had opted for comfort care and one of them was put on NPPV—apparently against his wishes. Included in the mix are DNR/DNI patients arriving in the ED with acute respiratory failure from COPD or pulmonary edema. While a DNR/DNI status minus a comfort care designation should not by itself automatically be a contraindication to any and all NPPV application, clinicians should still always keep center stage the question of whether we are helping to prolong the living process or prolong the dying process, for what about the nonsurvivors in the studies who were placed on NPPV? How many of them had bad deaths ushered in because of the imposition of NPPV? They might have been told that it would be an easy thing to both apply and remove the NPPV interface.

One of the studies¹⁷ goes so far as to create a picture of NPPV as tranquil and empowering, stating: “Treatment with NPPV can be stopped for short periods to allow conversation with staff or family and for eating or drinking. When NPPV is finally discontinued, the transition from NPPV to an oxygen mask is much simpler both ethically and technically than the transition from endotracheal intubation and can be directed or performed by the patient.” (But an endotracheal tube was not an option to begin with if they were DNI.)

What many other RTs and I have seen are situations like the following: The patient is DNI/DNR, had opted for comfort care, and is initially somewhat stable. Some curative efforts are still under way, lab work is being done, etc. Then at 2 am the patient suddenly becomes hypoxemic, becomes tachypneic, and is placed on a NRB mask with an Spo₂ of 78%. The nurse is in both reactive/curative mode by reflex. The physician is called. This physician is on call and not familiar with the patient. There was no previous order for morphine, and the easy way out—or the path of least resistance—for the physician is to just order bilevel positive air pressure. And it “works.” Like magic, the Spo₂ rises, the respiratory rate goes down, etc. But several days later, the mask is still on, IPAP is 14, EPAP is 10, Fio₂ is 1.0. No morphine has been ordered, because who wants to depress a respiratory drive on such a patient? Facial necrosis is setting in; the patient is becoming extremely irritated at having the mask on constantly and especially with the robust settings. A few nights later, once again the Spo₂ is dropping to less than 90%, dyspnea is setting in, etc. Now the contemplation of the sudden removal of NPPV seems akin to actively aiding and abetting the patient’s demise. In any event, it is no easy thing to just go back to an oxygen mask. The family is now made to feel active guilt if they agree to remove the NPPV device. Meanwhile, the patient starts to grab at the mask, the nurse wants to restrain the patient, and the respiratory therapist replies that NPPV patients cannot be restrained. The nurse replies to the RT, “But she’ll die if she doesn’t keep that mask on!” No morphine is ordered.

What About the Patients?
Consider the dying patients—patients who have various disease processes advanced enough such that they wish to have the focus of care shifted from curative to palliative: the relief of suffering. Some of these patients may indeed present with a potentially and temporarily reversible case of acute respiratory failure. Recent studies cited to supposedly justify the use of NPPV always point to some short-term survival benefit. But is the glass also more than half empty as the nonsurvivors suffer a bad death because NPPV was used as a way to deny that life was ending.?

We bemoan the health care system that somehow is producing thousands of deaths due to medical error.¹⁹ We are supposed to emulate the airline industry to bolster patient safety.^20,21 While this effort has much merit, it must also be pointed out that no sane airline would agree to fly the “planes of futility” we often do. All the “magic acts” of futility would stay on the ground. Imagine a 90-year-old patient with pancreatic cancer who is DNR/DNI and who suddenly goes into respiratory failure and is placed on NPPV and kept on a floor ward. (And really it matters not for this comparison if the patient is comfort care or not.) Now imagine the relevant analogy of the airline industry trying to keep such a “plane” aloft without an error or crash. Eventually, a crash occurs and it is chalked up as some type of error. Indeed.

If we are going to decide to fight for life, there can be no middle ground—any more than there should be any middle ground for airline safety. NPPV should be used only if its failure is to be followed by intubation. If we are going to respect our patient’s wishes, accept death, and turn our clinical attention to comfort or palliative care, then NPPV has no place.

Jeff Whitnack, RRT/RPFT, is lead respiratory therapist, Sequoia Hospital, Redwood City, Calif.

References
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