title: The Role of Noninvasive Ventilation in Patients with "Do Not Intubate" Order in the Emergency Setting.
abstract: BACKGROUND
  Noninvasive ventilation (NIV) is being used increasingly in patients who have a "do not intubate" (DNI) order. However, the impact of NIV on the clinical and health-related quality of life (HRQOL) in the emergency setting is not known, nor is its effectiveness for relieving symptoms in end-of-life care.
  
  
  OBJECTIVE
  The aim of this prospective study was to determine the outcome and HRQOL impact of regular use of NIV outcomes on patients with a DNI order who were admitted to the emergency room department (ED).
  
  
  METHODS
  Eligible for participation were DNI-status patients who receive NIV for acute or acute-on-chronic respiratory failure when admitted to the ED of a tertiary care, university-affiliated, 600-bed hospital between January 2014 and December 2014. Patients were divided into 2 groups: (1) those whose DNI order related to a decision to withhold therapy and (2) those for whom any treatment, including NIV, was provided for symptom relief only. HRQOL was evaluated only in group 1, using the 12-item Short Form Health Survey (SF-12). Long-term outcome was evaluated 90 days after hospital discharge by means of a telephone interview.
  
  
  RESULTS
  During the study period 1727 patients were admitted to the ED, 243 were submitted to NIV and 70 (29%) were included in the study. Twenty-nine (41%) of the 70 enrollees received NIV for symptom relief only (group2). Active cancer [7% vs 35%, p = 0,004] and neuromuscular diseases [0% vs. 17%] were more prevalent in this group. NIV was stopped in 59% of the patients in group 2 due to lake of clinical benefit. The in-hospital mortality rate was 37% for group 1 and 86% for group 2 0,001). Among patients who were discharged from hospital, 23% of the group 1 and all patients in group 2 died within 90 days. Relative to baseline, no significant decline in HRQOL occurred in group 1 by 90 days postdischarge.
  
  
  CONCLUSIONS
  The survival rate was 49% among DNI-status patients for whom NIV was used as a treatment in ED, and these patients did not experience a decline in HRQOL throughout the study. NIV did not provide significant relief of symptoms in more than half the patients who receive it for that purpose.
authors.affiliation: Medicine Integrated Master (MIM), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Oporto University (UP), Porto, Portugal.
authors.forename: Marta
authors.initials: M
authors.lastname: Vilaça
authors.affiliation: Intensive Care Unit (UCIP), Oporto Hospital Center, Porto, Portugal.
authors.forename: Irene
authors.initials: I
authors.lastname: Aragão
authors.affiliation: Intensive Care Unit (UCIP), Oporto Hospital Center, Porto, Portugal.
authors.forename: Teresa
authors.initials: T
authors.lastname: Cardoso
authors.affiliation: Center for Health Technology and Services Research (CINTESIS) and Information Sciences and Decision on Health Department (CIDES), Faculty of Medicine, Oporto University (UP), Porto, Portugal.
authors.forename: Cláudia
authors.initials: C
authors.lastname: Dias
authors.affiliation: Intensive Care Unit (UCIP), Oporto Hospital Center, Porto, Portugal.
authors.forename: Glória
authors.initials: G
authors.lastname: Cabral-Campello
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D018572:Disease-Free Survival; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D011788:Quality of Life; D012121:Respiration, Artificial / Q000379:methods*; D012131:Respiratory Insufficiency / Q000401:mortality / Q000628:therapy*; D015996:Survival Rate