Palliative use of noninvasive ventilation: navigating murky waters.
BACKGROUND
The use of noninvasive positive pressure ventilation (NPPV) as a palliative treatment for respiratory failure and dyspnea has become increasingly common. NPPV has a well-established, evidence-based role in the management of respiratory failure due to acute exacerbations of congestive heart failure and chronic obstructive pulmonary disease, both for patients with and without restrictions on endotracheal intubation. There are emerging uses of NPPV in patients clearly nearing the end-of-life, but the evidence to support these applications is limited. Alongside these emerging applications of NPPV are new ethical dilemmas that should be considered in medical decision-making regarding these therapies.


CONCLUSIONS
Herein, we describe the use of NPPV in four patients with advanced disease and preexisting treatment-limiting directives. We discuss some of the ethical dilemmas and unintended consequences that may accompany the use of NPPV in such circumstances, and we review the benefits and burdens of palliative NPPV.


CONCLUSIONS
Finally, we conclude with a summary of principles that can be used as a guide to decision making regarding palliative NPPV.
1 Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center , Rochester, New York.
Caroline M
CM
Quill
Timothy E
TE
Quill
D016223:Advance Directives; D000368:Aged; D002283:Carcinoma, Bronchogenic / Q000150:complications / Q000628:therapy; D003657:Decision Making / Q000941:ethics; D018450:Disease Progression; D004417:Dyspnea / Q000209:etiology / Q000628:therapy*; D005190:Family / Q000523:psychology; D005260:Female; D006801:Humans; D054990:Idiopathic Pulmonary Fibrosis / Q000150:complications / Q000628:therapy; D008175:Lung Neoplasms / Q000150:complications / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D063087:Noninvasive Ventilation / Q000379:methods*; D010166:Palliative Care / Q000379:methods / Q000592:standards*; D011175:Positive-Pressure Respiration / Q000379:methods*; D011379:Prognosis; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications / Q000628:therapy; D012131:Respiratory Insufficiency / Q000209:etiology / Q000628:therapy*; D016414:Resuscitation Orders; D019452:Terminally Ill