Authors (including presenting author) :
Chan SH, Yau WT, Leung MW
Affiliation :
Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong
Introduction :
In acute wards, even patients are imminently dying and receive end-of-life (EOL) care, some are still on life-sustaining treatments like mechanical ventilation. Family can decide for mechanical ventilation withdrawal to relieve patient's suffering. However, it is a challenging clinical intervention as it involves ethical issues, terminal weaning methods, patient comfort and family support. There was a case about terminal extubation in our acute ward. A 84-year-old patient was admitted on 31/3/2019 and diagnosed with post-cardiac arrest and acute coronary syndrome. She was intubated and had a Glasgow Coma Scale of 3/15 indicating deep unconsciousness. There was no neurological recovery despite sedation was stopped. Family opted for comfort care with a Do-Not-Attempt Cardiopulmonary Resuscitation (DNACPR) order in place. On 10/4/2019, family refused further suffering of patient and wished for terminal extubation.
Objectives :
1. To ensure patient comfort during the dying process. 2. To help the patient to have a peaceful and dignified death. 3. To support the family and reduce predictable psychological distress.
Methodology :
Good practice and special care provided: 1. Parent team consulted respiratory and palliative teams for support. 2. Family was fully explained that death will come for the patient within a short period of time after extubation. 3. Parent team negotiated with family about conflicts that may arise around decision making and ensured all family members had reached consensus to proceed with terminal extubation. 4. Medical social worker and chaplain service were referred for on-site support. 5. Intravenous morphine infusion was administered to patient before withdrawal from mechanical ventilator to ensure comfort and relieve symptoms of distress.
Result & Outcome :
Terminal extubation was performed as planned on 14/4/2019. Healthcare staff allowed flexible visiting hours and facilitated more space for family to accompany patient in the last days of life. Patient was certified death three days later. Family was involved to clean the body of the patient as they wished before performing last office. It was a successful case of delivering quality EOL care to imminently dying patient with terminal extubation and her family in acute ward setting. Symptoms relief, psycho-spiritual support and bereavement care for the family are addressed in the end of the patient's life journey. As a result, the patient could have a peaceful and dignified death.
