Abstract
Mrs. Williams is an 82-year-old woman with severe chronic obstructive pulmonary disease (COPD), hypertension, and diastolic heart failure who is admitted to the medical intensive care unit (ICU) with acute hypercapnic/hypoxemic respiratory failure necessitating rescue noninvasive bilevel positive airway pressure. She seems to be fatigued and volume overloaded on physical examination, with coarse breath sounds bilaterally. You have started diuretics and empiric treatment for a COPD exacerbation, but you worry that she may not be responding adequately to noninvasive ventilation. This is her third admission in the last 6 months. She has never required intubation, and from a brief chart review, it does not seem that intubation has been previously discussed in detail.
Case
Mrs. Williams is an 82-year-old woman with severe chronic obstructive pulmonary disease (COPD), hypertension, and diastolic heart failure who is admitted to the medical intensive care unit (ICU) with acute hypercapnic/hypoxemic respiratory failure necessitating rescue noninvasive bilevel positive airway pressure. She seems to be fatigued and volume overloaded on physical examination, with coarse breath sounds bilaterally. You have started diuretics and empiric treatment for a COPD exacerbation, but you worry that she may not be responding adequately to noninvasive ventilation. This is her third admission in the last 6 months. She has never required intubation, and from a brief chart review, it does not seem that intubation has been previously discussed in detail.
Respiratory failure is a common indication for admission to an ICU and can be a frequent complication of critical illness.1 There are many different etiologies for acute respiratory failure, and the likelihood of recovery varies by underlying etiology and specific patient factors such as age, chronic comorbidities, and other acute organ failure.2, 3 While intubation and invasive mechanical ventilation can be utilized as a rescue strategy for acute respiratory failure, not all patients will find these interventions acceptable, nor is the benefit from the intervention uniform across individuals. There is substantial ethical and legal consensus that patients and their families have the right to decline life-sustaining therapies, including intubation and mechanical ventilation.4, 5
In this chapter we will discuss the need for timely, context-specific conversations with patients and families about intubation. We will review the evidence on prognosis for patients with acute respiratory failure, suggest ways to elicit patient and family values around intubation, and describe a proposed approach to assessing the “Do-Not-Intubate” order.
6.1 The Need to Discuss Intubation Preferences in the ICU
Despite a generalized expectation of “assessing code status” for all hospitalized patients upon admission, research shows that detailed and patient-centered discussions around intubation status often do not occur, and when conversations do take place, patients are frequently not given an opportunity to ask questions and remain confused about the features of resuscitation.6, 7 Furthermore, preferences for intubation are often context-specific and can change over time.8, 9 In a study assessing patient preferences for intubation among only patients with documented code status as DNR/DNI, Jesus et al. found that over half of patients would accept intubation for a specific, hypothetical clinical situation, highlighting the need for physicians to have timely, context-specific conversations with patients at risk of requiring intubation.10 In addition, it is vital to avoid conflating decisions to forgo cardiopulmonary resuscitation for cardiac arrest and mechanical ventilation for respiratory failure.11 This is important given the different prognoses of patients with isolated respiratory failure compared to those who suffer cardiac arrest.
6.2 Epidemiology of Acute Respiratory Failure
Prognostication in acute respiratory failure is challenging as outcomes vary both by the underlying etiology of respiratory failure and by individual patient characteristics, such as age and presence of other comorbid conditions.12 The five most common etiologies for acute respiratory failure requiring mechanical ventilation in the United States between 2001 and 2009 were pneumonia, congestive heart failure, COPD, acute respiratory distress syndrome, and sepsis.2 In a very large, prospective cohort study of 369 ICUs from 20 different countries, the observed ICU mortality for patients requiring mechanical ventilation was 30.7%.13 While observed ICU and hospital mortality for patients undergoing invasive mechanical ventilation has decreased over time, improvements have not been uniform across etiologies of respiratory failure.14 Favorable trends have been observed in pneumonia and COPD, but for congestive heart failure, hospital mortality has not improved (Figure 6.1).14
Figure 6.1 Unadjusted hospital mortality for patients receiving invasive mechanical ventilation in the United States: 1993–2009. Abbreviations: IMV – Invasive mechanical ventilation, COPD – chronic obstructive pulmonary disease, HF- heart failure, PNA – pneumonia.
Patient-specific factors associated with in-hospital mortality from acute respiratory failure include age, chronic comorbidities, and the presence of other acute organ failures.15 Older age is associated with increased risk of hospital death from respiratory failure. In a prospective study of a mixed medical and surgical ICU population, hospital and 3-month mortality rates were substantially better among patients with single organ acute respiratory failure (15% and 22%, respectively) compared to patients with any other acute organ failure (41% and 47%, respectively).3
Certain chronic comorbidities, such as underlying cancer, are also associated with poor survival. For example, in a review of 22 studies of over 3000 cancer patients experiencing respiratory failure requiring invasive mechanical ventilation, average ICU survival was 32.4% and long-term survival (ranging from two to six-months) was 10.2%.16 Within the cancer population, the presence of chronic comorbidities and other acute organ failure, in addition to baseline performance status, are also associated with decreased survival.
6.3 Prognostication in Acute Respiratory Failure
Population-based and disease-specific epidemiologic data can be helpful, but are insufficient when considering the prognosis of an individual patient at the bedside. Modern severity of illness measures have been demonstrated to accurately estimate the risk of death in populations of critically ill patients, but they generally fail to predict outcomes for individuals with the certainty needed to make real-time decisions at the bedside.17 Furthermore, survival alone is not the only outcome important to patients and their families. Physical function, cognition, mental health, health-related quality of life, and pain have all been identified as outcomes important to survivors of acute respiratory failure.18 For many patients and their families, these functional outcomes are more important than survival alone.19
Incorporating likelihood of survival in decision-making for patients with acute respiratory failure is particularly challenging as the certainty of death without the intervention in question (intubation and mechanical ventilation) often approaches 100%. Rather than focusing on survival alone, patients and families may benefit from discussions with providers regarding what survival might look like. Ideally, a clinician would be able to advise the patient and family on outcomes such as the patient’s expected functional status, probability of returning home, or ability to return to work, and seek to understand how these possible outcomes do or do not align with the patient’s values and preferences can both help guide decision-making as well as prepare families for potentially challenging recovery periods.20, 21 Of course, these outcomes are also difficult to predict for individual patients, and preferences may change over time.9
6.4 Proposed Approach to the “Do-Not-Intubate” Order
Here we outline the approach to utilizing shared decision-making in the choice to undergo intubation and mechanical ventilation. This approach is adapted from models described previously.22, 23 The feasibility of completing all elements of this process may be limited by factors beyond the providers’ control, such as patient severity of illness and acuity of respiratory failure, among others. However, if time and acuity allow, this process can serve as an idealized model for guiding discussions surrounding intubation status.
6.4.1 Set the Stage
This first step is often an information exchange in which the provider should discuss the patient’s prognosis and the reasons for having a conversation about intubation and mechanical ventilation. The provider should offer the patient and family the opportunity to ask questions about the current clinical status as well as prognosis, answer those questions to the best of their ability, and ensure understanding of that prognosis.
6.4.2 Values Elicitation
The second step is for the clinician to elicit the patient’s general values and goals for care. While previous approaches often described this step as outlining a “menu of options” and determining which interventions on that list the patient would be willing to accept, we advocate for a more holistic approach to understanding the patient’s goals, values, and fears. Asking patients about their hopes and expectations for their health can be helpful. While the use of a structured conversation guide and training program to help provide clinicians with language to ask patients about their goals, values, and wishes has demonstrated promise in other health-care settings, this has yet to be studied in the ICU.24, 25 Below, we include some suggested phrasing for value elicitation adapted to the ICU setting.
6.4.3 Description of Intervention
In the context of the patient’s expressed values, the clinician can now fully explain the potential intervention under consideration – in this case, intubation and mechanical ventilation. The clinician should confirm that the patient understands the nature of intubation and mechanical ventilation, their likelihood of requiring it, and its risks, benefits, and possible outcomes. Clearly, the possible outcomes are tightly linked to the patient’s overall prognosis, and in some circumstances, this can be difficult to personalize with great certainty. In general, where there is clinical uncertainty, the clinician should acknowledge it honestly.
Related posts:
Chapter 2 – How Much Does the Family Want to Be Involved in Decision-Making?
Chapter 4 – Communication Skills for Critical Care Family Meetings
Chapter 5 – The Do-Not-Resuscitate Order
Chapter 14 – Potentially Inappropriate Treatment and Conscientious Objection
Chapter 20 – Brain Death Discussions
Chapter 13 – Severe Traumatic Spinal Cord Injury
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