What Matters Most When
Considering Noninvasive Ventilation for
Patients With Do-Not-Intubate or
Comfort-Measures-Only Orders?*
Utilizing noninvasive ventilation (NIV)
for patients with do-not-intubate (DNI) or
comfort-measures-only (CMO) orders remains controversial, despite decades of
debate over this issue (1). Some argue that the use of NIV in these patients
provides improved chances for survival and achieves important aims, such as
improving patient comfort or providing additional time for patients to interact
with loved ones or to fulfill meaningful end-of-life tasks (2, 3). Others claim
that implementing NIV in this setting is more likely to produce harm than
benefit, constitutes an unjust use of limited healthcare resources, and merely
prolongs the dying process (4, 5). However, neither proponents nor opponents of
NIV in this setting have had sufficient evidence to support their viewpoints,
so the controversy has remained largely unresolved.
In this issue of Critical Care
Medicine, Wilson et al (6) provide the first
systematic review and meta-analysis exploring the outcomes of NIV in patients
with acute respiratory failure (ARF) who have DNI or CMO orders. Among patients
with DNI orders (2,020 patients, 27 studies), they assessed pooled survival
rates to hospital discharge (56%) and at 1 year (32%). Hospital survival rates
were highest among patients with chronic obstructive pulmonary disease and
pulmonary edema (68%) but much lower for patients with active malignancy (37%).
Importantly, they found that survival was comparable regardless of whether
patients received NIV in the ICU or in a “well-equipped” hospital ward.
Patients generally tolerated NIV well, and those who survived returned to their
baseline quality of life (QOL) within 3
months following discharge…
No comments:
Post a Comment