Terminal withdrawal of mechanical ventilation at a long-term acute care hospital: comparison with a medical ICU.
BACKGROUND
Failure to wean from prolonged mechanical ventilation (MV) is common in long-term acute care hospitals (LTACHs), but the process of terminal withdrawal of MV in LTACHs is not well described. We compared terminal withdrawal of MV at an LTACH with that in a medical ICU (MICU).


METHODS
A retrospective medical chart review was done of all patients undergoing terminal withdrawal of MV in an LTACH (n = 30) and in a MICU (n = 74) over a 2-year period.


RESULTS
The decision to withdraw MV was more likely initiated by patient or family in the LTACH and by medical staff in the MICU (p < 0.0001). Social workers, pastoral care, and hospital administration were more likely to participate in the withdrawal process at the LTACH compared with the MICU (p < 0.05). Time from initiation of MV to orders for do not resuscitate, comfort measures only, or withdrawal of MV was significantly greater in the LTACH (weeks) compared with the MICU (days) (p < 0.05). The dose of benzodiazepines given during the final 24 h of life was greater in the MICU as compared with the LTACH (p < 0.05). Narcotic and benzodiazepine use in the hour before or after withdrawal of MV did not differ between the two groups. COPD and pneumonia were the most common causes of death among patients undergoing withdrawal of MV at the LTACH, as opposed to septic shock in the MICU (p < 0.05).


CONCLUSIONS
Terminal withdrawal of MV in the LTACH differs from that in the MICU with regard to decision making, benzodiazepine use, and cause of death.
White
Alexander C
AC
Department of Pulmonary and Sleep Medicine, Rose Kalman Research Center, New England Sinai Hospital, Stoughton, MA. Electronic address: awhite@nesinai.org.
Joseph
Bernard
B
Department of Pulmonary and Sleep Medicine, Rose Kalman Research Center, New England Sinai Hospital, Stoughton, MA.
Gireesh
Arvind
A
Department of Pulmonary and Sleep Medicine, Rose Kalman Research Center, New England Sinai Hospital, Stoughton, MA.
Shantilal
Priya
P
Pulmonary, Critical Care, and Sleep Division, Tufts Medical Center, Boston, MA.
Garpestad
Erik
E
Pulmonary, Critical Care, and Sleep Division, Tufts Medical Center, Boston, MA.
Hill
Nicholas S
NS
Pulmonary, Critical Care, and Sleep Division, Tufts Medical Center, Boston, MA.
O'Connor
Heidi H
HH
Department of Pulmonary and Sleep Medicine, Rose Kalman Research Center, New England Sinai Hospital, Stoughton, MA.
D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D015331:Cohort Studies; D003657:Decision Making; D005260:Female; D006769:Hospitals, General; D006801:Humans; D007362:Intensive Care Units; D008020:Life Support Care / Q000592:standards / Q000639:trends; D008134:Long-Term Care; D008297:Male; D008875:Middle Aged; D010358:Patient Participation; D010817:Physician-Patient Relations; D011336:Probability; D012121:Respiration, Artificial / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D013727:Terminal Care / Q000379:methods*; D013997:Time Factors; D028761:Withholding Treatment