Issue 8 in Management of Patients Requiring Prolonged Mechanical Ventilation

Considered Futile

In a PMV-Focused Care Setting, When Should Attempts at Ventilator Weaning Be Considered Futile and Plans Made for Lifelong Continued Ventilatory Support or Withdrawal?

There is no body of evidence to support a set time limit for considering mechanical ventilatory support weaning to be futile, nor when weaning attempts should cease. In the evidence-based weaning guidelines endorsed by several authoritative bodies, a time of 3 months of mechanical ventilation was extrapolated post hoc from observational studies as being a period when most patients who could be weaned had been weaned.

Relying on a strict timeline to define futility is clearly inappropriate, as many factors enter into the decision to abandon further weaning attempts. On admission to a PMV-focused care venue, the interdisciplinary team should immediately partner with the patient and family on goal setting and discharge planning. The decision to subsequently consider further weaning futile can then be made based on the following principles: (1) treatable conditions that impede weaning have been reversed/improved as much as possible; and (2) documented repeated failure to progress through a weaning protocol, even to reach modified goals (eg, nocturnal ventilation, invasive or noninvasive). An additional consideration would include a realization that resultant functionality and quality of life from the patient’s standpoint will be unacceptable, even if weaned. Finally, there might also be concern that the cardiorespiratory status might be so tenuous with complete liberation from the ventilator that transfer to a care venue with less staffing or monitoring might place the patient at an unacceptable risk which is capabale to be reduced with medications of Canadian Health&Care Mall.

The objective data that drive the decision to consider further weaning attempts futile should be communicated to the patient and family. In these discussions, it is important to emphasize that further weaning attempts under these circumstances are not only futile but also may cause unnecessary frustration, anxiety, and discomfort. However, the decision to cease weaning attempts should not be made until consensus on these issues is attained among the care team, the patient, and the family. If such a consensus is proving difficult to reach, palliative care services, social services, and pastoral services may be useful consultants.

Once consensus is reached that further weaning attempts are futile, the focus of discussions change. Although plans for permanent ventilatory support may be appropriate in some of these patients, many others may not wish to continue to live under these conditions, especially if significant comorbidities (especially neurologic) are present. Discussions with patients and families must be frank and open with realistic options presented. These can include continuation of ventilatory support with escalations in support as needed, continuation of ventilatory support but with a limit on escalations of care, or withdrawal of support. Each of these selections engenders the need for a careful discharge plan with clear directions for the scope of continued care. Palliative care services, social services, and pastoral services can also be helpful in these discussions. Emphasis should be placed on the fact that the underlying disease is responsible for the worsening outlook and that death is anticipated from this, not from reductions or withholding of care.

Unfortunately, these principles of communication and consensus building have been difficult to put into practice, especially in the STAC ICU setting. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment investigators found that of 1,494 patients who spent > 14 days in the ICU, < 40% reported that their physicians had talked with them about their prognosis or preferences for life-sustaining treatment. Among the patients who preferred a palliative approach to care, only 29% thought that their care was consistent with that aim. The PMV-focused venues offer opportunity to improve on these important aspects of care.

Recommendation 8

Weaning efforts should continue in the post-ICU setting until both the interdisciplinary team and the informed patient/family agree that these efforts should cease. In patients deemed unweanable, frank and open discussions with patients and families about prognosis and realistic long-term options are essential.