The Difficult-to-wean Patient

Nicolino Ambrosino; Luciano Gabbrielli


Expert Rev Resp Med. 2010;4(5):685-692. 

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Although advances in intensive care have allowed an increasing number of patients to survive an episode of ARF or ACRF, they have also created a large and growing population of patients with partial or complete dependence on MV and other intensive care therapies. These patients who neither die nor recover in the ICU have also been defined as 'chronically critically ill'. Recent estimates indicate that there are more than 100,000 such patients in the USA, a number that is also increasing in many other developed countries. This condition is devastating for patients and their families, and is also expensive. Incidence and expenditures are rising mainly due to older elderly adults receiving aggressive medical and surgical treatments. Most patients with chronic critical illness leave the hospital with severe derangements of physical and cognitive status, and therefore require institutional care or home familial or nonprofessional assistance. Hospital re-admission rates during the year after hospital discharge exceed 40%. Patients discharged to extended-care facilities who cannot return to home by 6 months usually remain institutionalized until death, if healthcare services provide these facilities. When facilities are lacking, this condition imposes heavy burdens on family members, who may suffer from depression and practical and financial hardships. Studies of the nonprofessional caregivers of patients requiring prolonged MV indicate that depressive symptoms are more severe in this group than among caregivers of patients with Alzheimer's disease or spinal cord injury and that depression continues for months after the patient is discharged from the hospital or dies. Moreover, these caregivers also report a decline in physical health and increase in 'caregiving overload' during the post-discharge period. These nonprofessional caregivers have to face tasks requiring high skills, such as management of tracheostomy, setting of ventilators and enteral nutrition, with relevant economical, psychological and emotional consequences, such to require hospital admission in order to give physical and psychological relief to the caregiver. In other words, these difficult-to-wean patients represent an example of the future challenges for public or private healthcare services, with disturbing questions such as these: 'In a globalized world is it worthwhile to spend human and financial resources to 'prolong suffering' of such patients whereas in some parts of the globe children have no water to survive?.'; 'Is it ethical to perform aggressive medical and surgical therapies for such patients with low life duration and high sufferance expectancy?.' This turns us to end of life decision making, an issue deserving a dedicated chapter, not only a commentary. A suggested approach has been the use of noninvasive MV in palliative care, a position still discussed.[83] There are different approaches among different countries on withholding and withdrawal of care, depending on religious, ethical and organizational factors. In a survey of European respiratory intermediate-care units and high-dependency units, an 'end of- life decision' was taken for 30% of the patients admitted. The most common practices were withholding treatment, the use of noninvasive MV as a ceiling therapy and provision of a do-not-resuscitate/do-not-intubate order, the latter occurring significantly more frequently in North Europe compared with South Europe. Patients, when competent, and their families were often involved, together with nurses, in reaching these key decisions.[84] Use of advance directives should be encouraged and accepted in all countries.[85,86]


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