Noninvasive ventilation at the end of life

Benditt, J.O.

Respiratory Care 45(11) 1376-1381; Discussion: 1381-1384


ISSN/ISBN: 0020-1324
PMID: 11063525
Document Number: 7227
NPPV, I believe, is a useful tool in the palliative care of some patients with terminal disease. It is a novel treatment option in that it can, in some cases, relieve the disabling and distressing symptom of dyspnea while at the same time prolonging life. Although this sounds superficially very attractive, many serious questions regarding the use of NPPV at the end of life remain to be answered. Clarke et al believe that the use of NPPV in patients with terminal diseases contradicts the biomedical ethics principle of nonmaleficence (do no harm) by subjecting the patient to uncomfortable interventions in hospital 22 They also contend that routine use of NPPV would result in vast monetary expenditures that could result in an unfair allocation of a scarce resource. The current situation is one in which the availability of a technology has pushed forward the use of a device in ways not previously envisioned. Clearly the blanket use of NPPV for the terminally ill with respiratory symptoms would be a grave error. In my practice I ask a series of questions that reassure me about the proper application of NPPV (Table 3). I demonstrate the noninvasive ventilation set-up to the patient and allow them to try the device. If, after the proper application, the noninvasive device is not relieving the symptoms as desired by the patient, I remove the device and institute other palliative measures. The most important point is ongoing communication with the patient and family, with clear goal-setting being of utmost importance. My own sense is that NPPV represents a very positive advance as an alternative for the relief of dyspnea at the end of life, which must be used in concert with other techniques, including the use of narcotics, anxiolytics, and compassionate communication and care. I focus on determining what is the best tool to help the patient and his or her family realize their goals during this difficult period. NPPV is one of the tools that we can use to improve the quality of life of the patient with terminal disease.

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Noninvasive ventilation at the end of life