End of Life (EOL) Care: Removal of Mechanical Ventilation (RMV) for the Dying Critical Care Patient Kathleen Hoff MSN, CCRN, FNP-BC

UC Healthcare

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Background: Federal Law

Patients have the right to accept or reject medical treatment

In Critical Care Units as up to 95% of patients may not be able to make decisions known

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Background One in five Americans will die after

receiving care in the critical care area

22% of all deaths in the Untied States occur in the ICU – many marked with suffering both within physical & emotive domains

The critical care setting is a multifaceted and innovative environment where death is not considered a normal process of life

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Background Limiting or withdrawing life support is not ethically or legally wrong Quality of life at the end of life has become a priority and universal concern for critical care healthcare professionals

Mechanical ventilation is one of the most common treatments to be withdrawn once focus changes to comfort/end-of-life care

Availability of clinical guidelines for removal of mechanical ventilation (RMV) for the dying critical care patient have not been developed

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Background

End of Life (EOL): Removal of Mechanical Ventilation (RMV) Algorithm will assist the Interdisclinpary team to provide essential comfort care when the goal is to remove the ventilator for the dying critical care patient Education of EOL care is supported by National & Worldwide Healthcare Organizations

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Goal of Project

To provide the patient in the ICU improved End of

Life (EOL) Care:

Removal of Mechanical Ventilation (RMV) and

Medication Administration by

Education of EOL: RMV Algorithm

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Assessment & identification of dying patients on mechanical ventilation: Curative strategies unlikely to meet desired goals of care

Implementation of RMV Clinical Algorithm & Guideline

Referrals: Social Service

Chaplin Palliative Care team

Ethics Team TIPS: Trauma Crisis Intervention

RMV Clinical Algorithm &

Guideline Tool

•Possible inconsistent & inappropriate end of life measures or interventions •Disparities in plan of care •Barriers and possible conflicts •Ineffective communication •Inconsistencies of measures & end of life interventions

•Appropriate end of life measures & interventions •Consistent plan of care •Decreased barriers and decreased conflicts •Effective communication •Implementation of end of life measures & interventions

Interdisciplinary Team (IDT) Planning

Family Conference

Removal of mechanical ventilator (RMV)

Peaceful &

Comfortable

Death for Patient

No Yes

Plan of care for Dying ICU Patient:

Identification & clarification of end of life measures & interventions

Methodology Conceptual Framework for Removal of Mechanical Ventilation for the Dying Critical Care or Intensive Care (ICU) Patient

Plan of care for Dying ICU Patient: Identification & clarification of end of life

measures & interventions

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Recommendations for Improvements for EOL care

Develop, educate, Implement & evaluate end of life care algorithms or guidelines

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Develop a Strategic Plan & Choose your Team EP7e, CNIII Project.pdf

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Why Project is Important:

Disparity continues to exist between the actual and the desired state of EOL care in the United States

Awareness, support for, and changes are occurring and needed to make improvements with EOL care

In critical care does EOL care start only when the patient is actively dying – during the last days of the person’s life?

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EOL Research - Critical Care Nurses Perspectives: Recent Studies Conducted

Providing End-of-life Care to Patients: Critical Care Nurses’ perceived Obstacles and Support behaviors (2005)

Providing a “Good Death”: Critical Care Nurses’ Suggestions for Improving End-of-Life Care (2006)

Current Practice for Withdrawal of Life Support in Intensive Care Units (2010)

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Study Results Obstacles

Largest – behaviors of the patient's family that remove the nurse from care for the patient

Physician disagreement regarding the direction of the dying patient’s care

Prolongs and/or increases patient’s suffering

Support Behaviors

Allowing patient’s family members adequate time alone with the patient after death

Providing peaceful & dignified bedside scenes after death

Teaching patient’s family how to act around a dying patient

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CN III Project Objectives

Method/Project Component

Outcome Measurement

Assess Interdisclinpary Team Perceptions of EOL Care

Implementation of Clinicians' Perceptions of EOL Care using the QOOD

Review of Interdisciplinary pre-education questionnaire results

Education of EOL: RMV Algorithm

Educational In-services Visual Poster Board of RMV algorithm Access to Algorithm on Clinical Guideline Web-Site

Critical care nurses & Interdisciplinary team members will receive education of RMV algorithm

Post-Education Questionnaire for critical care nurses

Develop post education Questionnaire

Review results of questionnaire

Development of Quest order-set for RMV Ventilator Modes & Medication administration

Use Quest Order-set template

Completed Order-set

Implementation of RMV Algorithm

Development of Monitoring Tool

Monitoring of RMV patients

Post CN III Project Reassess Interdisclinpary Team Perceptions of EOL Care after education

Repeat Clinicians' Perceptions of EOL Care using the QOOD

Review of post educational questionnaire results Prose methodology and results for study for publication

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Project Timeline Dates

Obtain Approval for CN III Project September 2011

Meet with Nursing Research Committee October 2011

Implementation of Clinicians’ Perceptions Questionnaire Study

October & November 2011

Education of RMV Algorithm & nursing post education questionnaire

December & January

Quest RMV Order-Sets DBT

Meet with Nursing Research Committee February 2012

Monitoring use RMV Algorithm On-going

Repeat Implementation of Clinician’s Perceptions Questionnaire Study

May & June 2012

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Goal of Algorithm

To provide comfort measures or interventions with compassion and respect

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Clinical Algorithm: End of Life Care Removal of Mechanical Ventilation (RMV)

Hoff, Lekawa,Williams, & Espinosa

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Research tells us…When

Algorithms or Guidelines

are implemented it is more likely…

EOL care is improved therefore…

Critical Care patients and their families are provided with

comfort, peace and dignity

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Thank You… Questions?

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