Noninvasive Ventilation Rare, but Becoming More Common at End of Life

By Lisa Rapaport

October 20, 2020

(Reuters Health) - A growing number of Medicare beneficiaries are receiving noninvasive mechanical ventilation instead of invasive mechanical ventilation at the end of life, particularly if they have cancer or dementia, a new U.S. study suggests.

Researchers examined data on a random sample of 20% of Medicare fee-for-service beneficiaries who died between 2000 and 2017 and had acute hospitalizations within their last 30 days of life. Of the 2.47 million Medicare beneficiaries included in the analysis, about 401,419 (16.3%) received invasive mechanical ventilation, while 90,700 (3.7%) received noninvasive mechanical ventilation and 25,689 (1.0%) received both.

Noninvasive mechanical ventilation (NIV) usage surged almost 9-fold in absolute terms during the study period, from 0.8% in 2000 to 7.1% in 2017. The absolute increase for invasive mechanical ventilation was more modest, rising from 15.0% in 2000 to 18.5% in 2017.

"There is a sense that non-invasive is less burdensome at the end of life than invasive mechanical ventilation, and there are some small studies suggesting NIV could be used for palliation in certain groups," said lead study author Dr. Donald Sullivan, an associate professor of medicine at Oregon Health and Science University and an investigator at the Center to Improve Veteran Involvement in Care (CIVIC) at the Portland VA Healthcare System.

"The trouble with this rationale for the expansion in noninvasive mechanical ventilation that we found is that we also found noninvasive mechanical ventilation was not replacing invasive mechanical ventilation," Dr. Sullivan said by email.

Instead, both forms of mechanical ventilation increased, suggesting that more patients at the end of life are getting aggressive care at the end of life that may not be patient- or family-friendly or support palliative care goals, Dr. Sullivan said. "This likely represents low-value care in which the risks outweigh the benefits."

From 2000 to 2017, the adjusted odds ratio (aOR) for increased use of noninvasive mechanical ventilation was particularly high for people with cancer and dementia (aOR 10.82 and 9.62, respectively).

Compared to patients who received invasive mechanical ventilation at the end of life, those who received noninvasive mechanical ventilation had lower rates of in-hospital death (76.6% v 50.3); lower rates hospice enrollment in the final three days of life (63.0% v 57.7%); and higher rates of hospice usage (41.3% v 20.0%).

One limitation of the study is that it used Medicare claims data, which doesn't offer clinical information about disease severity or patient and family preferences for end-of-life care, the study team notes in JAMA Internal Medicine.

It's also possible that results from Medicare fee-for-service enrollees may not be generalizable to people with Medicare managed care plans or other types of public or private health coverage.

The study also doesn't shed light on why the rise in noninvasive mechanical ventilation wasn't accompanied by a decline in usage of invasive mechanical ventilation, said Dr. Anand Iyer, an assistant professor in the division of pulmonary, allergy, and critical care medicine at the University of Alabama at Birmingham who wrote an invited commentary accompanying the study.

"Older adults at the very end of life are a very vulnerable group in whom noninvasive mechanical ventilation could potentially do more harm or increase suffering, and from this study, it does not appear to have led to a reciprocal reduction in invasive mechanical ventilation use in these particular patients," Dr. Iyer said by email.

"As a field, we really need to understand what clinicians are doing at the bedside when they place an older adult with advanced cancer or dementia on noninvasive mechanical ventilation at the very end of life," Dr. Iyer added. "There could be many reasons; however, we should ask does the evidence support those uses?"

SOURCE: https://bit.ly/3dEfm8I and https://bit.ly/2T7ASJR JAMA Internal Medicine, online October 19, 2020.

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