Bipap

I was working on a medical floor a while back when a pt's status was changed to CMO. He had been resting comfortably wearing a bipap but his family asked that it be removed. His nurse was uncomfortable about it but the doctor said that's what is done in hospice and overruled her. The respitory therapist came and removed the bipap. The pt was visibly uncomfortable and it took a long time and a lot of morphine to make him comfortable. To me, the whole thing felt wrong, so I'm turning to those of you who know hospice.

Is removing the bipap standard? If so, would you premedicate? It bothered all of us on the floor that day, that a pt who had been comfortable appeared to suffer the way he did.

I am a hospice and palliative care nurse and work in a hospital.

So when somebody is on bipap/cpap/high flow oxygen and the goals for care change to comfort (CMO) we usually discuss with the patient and relatives/HCP the implications. Usually the decision for CMO is done because the patient is at the end of life and does not want to spend the rest of the time left hooked up to a machine, unable to communicate and eat (bipap/cpap), plus there is the whole issue of getting trached if cpap/bipap support was needed longterm (and wished for).

Once the decision is made to become CMO we can address the problem of shortness of breath more aggressively with medication. The first step is usually to talk to patient and family and explain that we will medicate the patient to comfort. Once that is achieved the bipap/cpap can be taken off and exchanged for nasal canula. High flow can be weaned down and changed to nasal canula. I usually recommend to medication the patient to where comfort is achieved meaning RR less than 20 / min, patient relaxed, not appearing SOB / anxious. For some patients oral concentrated morphine sl in high dose and ativan sl is enough, others need iv bolus or drip - it depends on the dx and how they are doing. Sometimes this process can take some while because you want to transition gently to give patient and family time to adjust. Once comfortable the family should be prepared that it may be a quick progression and that this is normal. I also recommend to switch off the monitor because otherwise everybody gets panic...

When family and pat are comfortable make sure that pat had sacrament of the sick if catholic /priest / ask if anything religious is needed.

If ok , take off the mask and apply nasal canula, be prepared to administer narcotics iv and ativan to relief symptoms like SOB.

Another thing - if patient has already congestion i like them to have a scopolamine patch or receive levsin sl to dry out a bit.

Usually it works this way but if the mask or highflow is taken off and the pat starts to struggle and what not - they put the pat back on mask/high flow, medicate more and try again.

It can be very traumatic for the family to witness a dying patient struggle at the end of life so we try to make it as atraumatic as we can plus we do not want the pat to suffer.

Often, once the patient is finally comfortable, family feels relieved and they sit and share memories with the patient...

Hope this helps - yes we take off mask/high flow/pat gets extubated sometimes but it is important to do it the right way...

Thank you for taking the time to explain the process so well. I appreciate having this knowledge in case I face this situation with a patient I'm caring for.

I agree that the dying patient wishing to be off of the bipap should be off.

However, the objective is comfort and therefore the patient should be adequately premedicated with a solid plan for aggressive symptom management at the time of extubation or discontinuance of respiratory support.

I would have ensured the patient was comfortable prior to removing the bipap. Bipap is not an absolute contraindication to hospice...but in a hospital setting, I can see where it would be viewed as incompatible with goals of care. I have had patients on bipap on an inpatient hospice unit with the understanding that once we could wean them off comfortably, it would not be re-applied once discontinued.

I had an ALS hospice patient on a "sip-and-puff" ventilator once. So there aren't necessarily absolutes in the hospice world; it just needs to be very patient-specific with clear goals.