Ventilator support at end of life

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    What might the options be for the family of a patient that is on ventilator support but wants hospice. Letís say a patient is trached, a failure to wean off vent, not tolerating feedings thru peg, and has many health issue. Family does not want to do any further test, surgeries, aggressive interventions, but is not willing to discontinue the vent as the patient is still somewhat alert. What if the family wants the vent and to keep patient comfortable with Ativan and morphine. Will hospice accept a vent in this circumstance? Iíve seen this similar circumstance before, but the patient was intubated and not alert so family was okay with turning the vent off.
  2. 8 Comments so far...

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    OOPS ... double post!
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    My understanding is that hospice may not pay for interventions related to the hospice diagnosis that are intended to prolong life. As with artificial feeding, there are exceptions (but I can't think of one).

    It wouldn't hurt to get a hospice eval. If they feel they can't sign the patient on while still vented, there's nothing stopping the primary doc from getting a palliative care consult (different from hospice) and following their recommendations for comfort care.

    You didn't mention what setting this person is living in. If at home, they would miss out on the extra services hospice could provide ... but good comfort care is still possible through home health and good family education.

    If in a facility, some hospice organizations provide palliative consults and inservice education for bedside staff as part of their public relations/marketing.

    Some acute care hospitals also have their own palliative care services.

    The vented person is "somewhat alert" ... can s/he communicate? Has anyone asked this person what s/he wants?
    Last edit by heron on Sep 29, '12
    tewdles likes this.
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    I know hospice in my area would not accept a patient on a vent. Is the patient able to comunicate what they want?
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    The patient is confused and only shakes head yes and no to questions, but doesn't always answer appropriately. Unable to talk or write. In acute hospital setting.
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    Sounds like they could use a family meeting with the Doctor and IDT. They need clarification of prognosis and quality of life. Ask the family what his wishes are. Wether or not a Vent is appropriate for a hospice patient should be determined by the medical director. If the Pt is admitted for Ovarian CA the Vent would not be related. More than likely Palliative care might be the way to go until the family is Ok to DC vent.
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    My cousins father was vented, brought home from an ECF and went on hospice. He was not alert. He was in a persistent vegetative state and had a PEG tube. They never turned the vent off. He was only on hospice about 4 days before he passed.
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    Hospices are typically reluctant to admit patients who are ventilator dependent when the ventilator is directly related to the hospice dx. The presences of the ventilator is contrary to hospice goals, in general.

    I agree that the family requires an informational and educational meeting with the health care experts. The professionals need to be clear and extremely honest with this family. They need to use lay terms and talk about death and suffering and quality of life. The professionals should direct all conversation toward the patients goals, what is best for the patient, level of patient suffering, etc. If the family persists in making decisions that are not in the best interest of the patient, it is fair to ask them about their fears and anxieties and discover "who" and "what" they are actually treating with the patient ventilator continuation.

    These are not easy conferences or easy discussions and sometimes we make people angry although that is not our intention. Our job is to advocate for patients and when families realize that they are often thankful for our assistance in helping them put medical technology into perspective at end of life.
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    Our hospice did admit a patient on a ventilator. However, there was a continual re-evaluation of the goals of care, and eventually there was a consensus among the patient and the family to discontinue the ventilator. I think in these instances, the importance of the IDT and communication is paramount.
    tewdles likes this.


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