NIV - Escalation of therapy and palliation

Escalation of therapy

SectionRecommendationGrade of recommendation

18.

A clear plan for the parameters indicating escalation to intubation and ventilation in the event of NIV failure is to be documented on clinical presentation or initiation of therapy (1).

Consensus

19.

If the patient does not clinically improve within four hours of starting NIV the decision to intubate and ventilate is to be made (1).

A

20.

Intubation and ventilation is to be implemented rather than NIV continued for late failure (where late failure is defined as failure after 48 hours of NIV) (1).

B

21.

A clear plan for the parameters indicating the decision not to intubate and ventilate in the event of NIV failure is to be documented on clinical presentation or initiation of therapy. This decision is to be discussed between the patient (or enduring guardian) and treating medical specialist and documented in the clinical records (1).

Consensus

22.

An advanced health directive is to be completed for any future presentations if one has not previously been completed (2).

GL2005_056

The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations .

Escalation plans to invasive mechanical ventilation in the event of NIV failure should be documented in the patient’s clinical record on or at the onset of clinical presentation or within four hours of starting NIV (1). This discussion should occur with the patient and the treating medical specialist where possible. If the patient does not have the capacity to make this decision due to their physical condition, the patient’s enduring medical guardian needs to be included as their proxy. In the absence of an enduring guardian, the next of kin may be included in the discussion to escalate therapy however they have no legal capacity to provide consent (1, 3).

Clinical and physical parameters that may be recorded/documented and used to formulated a management plan for escalation to invasive mechanical ventilation include respiratory rate, chest wall movement, accessory muscle use, ventilator synchrony, heart rate, blood pressure, level of consciousness (AVPU or GCS) and ABGs (1).

“Late Failure” is defined as a failure to improve after 48 hours of NIV (1). It is suggested that for these patients escalation to invasive mechanical ventilation, rather than persisting with NIV, should occur.

If there is uncertainty or invasive mechanical ventilation is considered inappropriate the treating medical specialist, or appropriate proxy, is to discuss this with the patient (where possible), the patient’s enduring medical guardian and their next of kin. Documentation of the “not for intubation” plan and limitations to therapy are made in the clinical/medical records (1).

Due to limited literature specific to escalation of NIV to invasive mechanical ventilation, the level of evidence is low.

Palliation

SectionRecommendationGrade of recommendation

23.

Palliation for symptom relief, in combination with opioids and benzodiazepines, to treat breathlessness is to be documented on clinical presentation or initiation of therapy by medical staff. Such plans are to be implemented by nursing staff in response to assessment of patient comfort as required (1).

Consensus

24.

Patients with acute respiratory presentations associated with chronic medical conditions are:

  • to be asked if they have a current advanced health directive prior to the implementation of NIV. A significant other may provide evidence of any directives and should be included in this conversation.
  • Patients who do not have a current advanced health directive are to be provided with information relating to advanced care planning as part of an integrated care plan for management of their wishes for end-of-life care, once they are clinically stable (2).

Consensus

The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations .

Palliative care is increasingly recognised as an integral component of comprehensive care for all critically ill patients, regardless of prognosis (4). Pain management and optimal palliative therapy are part of the therapeutic targets for every patient with pain assessment and management falling within the comprehensive cope of care that should be provide concurrently with curative interventions and interdisciplinary care (5).

There is some literature relating to the development of advanced care directives for patients receiving invasive ventilation, but not specifically for NIV (6-8). The consensus of the development group for this CPG was to apply the evidence of best practice for the intubated/ventilated patient, to the patient receiving NIV.

Patients with current and legally valid advanced health directives must have their wishes in relation to end-of-life care honoured, irrespective of whether this is against the medical model of best practice for patients eligible for NIV (2).

Critically ill patients with medical conditions who require NIV and do not have a current advanced health directive are to be provided with information relating to advanced care planning as part of an integrated care plan for management of their wishes for end-of-life care. This should occur once they are clinically stable (2). Significant others, including next of kin, have no legal power to consent to an advanced health directive unless they hold enduring power of guardianship for the patient (NSW Guardianship Act 1987), however it is considered good clinical practice to include significant others when clinical decisions have been made relating to escalation or withdrawal of ventilation support (9).

Grading of recommendations

Grade of recommendation

Description

A

Body of evidence can be trusted to guide evidence

B

Body of evidence can be trusted to guide practice in most situations

C

Body of evidence provides some support for recommendation/s but care should be taken in its application

D

Body of evidence is weak and recommendation must be applied with caution

Consensus

Consensus was set as a median of ≥ 7

Grades A–D are based on NHMRC grades (10)

References

  1. Roberts CM, Brown JL, Reinhardt AK, Kaul S, Scales K, Mikelsons C, et al. Non-invasive ventilation in chronic obstructive pulmonary disease: management of acute type 2 respiratory failure. Clin Med. 2008;8(5):517-21.
  2. Officer OotCH. Advanced Care Directives NSW. Sydney: Ministry of Health; 2005.
  3. Guardianship Act, (1987).
  4. Nelson JE, Cortez TB, Curtis JR, Lustbader DR, Mosenthal AC, Mulkerin C, et al. Integrating palliative care in the ICU: the nurse in a leading role. Journal of hospice and palliative nursing: JHPN: the official journal of the Hospice and Palliative Nurses Association. 2011;13(2):89.
  5. Mularski RA, Puntillo K, Varkey B, Erstad BL, Grap MJ, Gilbert HC, et al. Pain management within the palliative and end-of-life care experience in the ICU. CHEST Journal. 2009;135(5):1360-9.
  6. Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, et al. Challenges in end-of-life care in the ICU. Intensive care medicine. 2004;30(5):770-84.
  7. Halpern NA, Pastores SM, Chou JF, Chawla S, Thaler HT. Advance directives in an oncologic intensive care unit: a contemporary analysis of their frequency, type, and impact. Journal of palliative medicine. 2011;14(4):483-9.
  8. Scherer Y, Jezewski MA, Graves B, Wu Y-WB, Bu X. Advance Directives and End-of-Life Decision Making Survey of Critical Care Nurses’ Knowledge, Attitude, and Experience. Critical Care Nurse. 2006;26(4):30-40.
  9. Papathanassoglou ED. Psychological support and outcomes for ICU patients. Nursing in critical care. 2010;15(3):118-28.
  10. NHMRC. Australian Guidelines for the Prevention and Control of Infection in Healthcare. Canberra: Commonwealth of Australia; 2010.

Disclaimer

The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.