EJRC Article Review

Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study)

Worldwide, an increasing number of deaths occur in the intensive care unit (ICU) after a decision to withdraw life support [1, 2]. Relatives of patients who die in the ICU have been reported to experience psychological distress manifesting as posttraumatic stress syndrome (PTSD)-related symptoms, complicated grief, anxiety, and/or depression, to degrees that vary according to the treatments provided and the quality of dying of the patient [3,4].

Withdrawal of mechanical ventilation holds a special place in the process of discontinuing life-sustaining treatments in ICU patients. Mechanical ventilation is withdrawn either by immediate extubation or by terminal weaning (gradual decrease in ventilatory support). The choice between these two methods is controversial, and whether it influences the experience of the patients and relatives is unclear [5, 6].

As few data are available for determining whether one method is superior over the other, the choice between the two methods is mainly a matter of opinion. The authors aimed to compare immediate extubation versus terminal weaning regarding:

– Comfort of patients during the dying process and wellbeing of ICU staff members,
– The long-term presence in relatives of PTSD-related symptoms, complicated grief, and symptoms of anxiety and depression.

A prospective, observational, multicentre study was conducted in 43 French ICUs, and included critically ill adults with a decision to withdraw invasive mechanical ventilation, and the main adult relative of each.

When withdrawal of mechanical ventilation was decided, either immediate extubation or terminal weaning was chosen by the ICU physician and other staff members, according to local practices and preferences of both relatives and ICU staff. Concomitant decisions to withdraw or withhold other treatments were at the discretion of the ICU staff.

In the resulting article published in Intensive Care Med (2017) [7], the authors reported some key findings:

• Immediate extubation and terminal weaning were each preferred by nearly identical proportions of ICU staff.
• The between-group differences in admission diagnoses suggest a preference for immediate extubation in comatose patients and for terminal weaning in patients with respiratory failure.
• Immediate extubation was associated with greater airway obstruction, a higher frequency of gasping, and higher BPS scores, but was not associated with a greater burden on the relatives compared to terminal weaning.
• Higher doses of opioids and sedatives were used in the patients undergoing terminal weaning, in whom previous respiratory and/or multi-organ failure was more severe than in the immediate extubation group.
• Time to death from extubation or first change in ventilator settings for terminal weaning did not differ between groups.
• In relatives, PTSD-related symptoms, complicated grief, and symptoms of anxiety and depression up to 1 year after the death were not significantly different between the two groups.
• In staff, the job strain of assistant nurses was lower with immediate extubation compared to terminal weaning.

Study Strengths & Limitations

The study has several strengths, namely that it is the first study to compare immediate extubation versus terminal weaning in terms of quality of death of critically ill patients, as assessed by the comfort of dying in patients and the psychological well-being of relatives and ICU staff, and also that it utilised a clear definition of terminal weaning and immediate extubation.

The limitations of this study mainly relate to the absence of randomisation, the lack of standardised end-of life care, and the absence of detailed evaluation or any provided recommendations concerning communication. However, the authors stated that the aim of the present study was to interfere as little as possible with the everyday practice of the ICU teams, so there were no modification of usual practices that could have generated bias due to reluctance of ICU staff to apply methods with which they felt uncomfortable. Additionally, all participating ICUs were in France, which limits the generalisability of findings.

Take Home Messages

• Considerable variation exists in practices for mechanical ventilation withdrawal in the ICU.
• Identifying personal beliefs that might constitute barriers to mechanical ventilation withdrawal is crucial when seeking to implement protocols for patient care.
• There seems to be a preference for immediate extubation in comatose patients and for terminal weaning in patients with respiratory failure.
• Patients had more airway obstruction and gasps with immediate extubation, indicating a need for better palliative care; however there was no difference on time to death between the two groups.
• Immediate extubation for mechanical ventilation withdrawal was not associated with differences in psychological welfare of relatives compared to terminal weaning, when each method constituted standard practice in the ICU where it was applied.
• This study suggests that, for the relatives, the two methods may result in similar experiences, provided the staff members are well trained in, and comfortable with, the method they apply.
• Compared to terminal weaning, immediate extubation was associated with less job strain in ICU staff.

This article review was submitted by ESICM Journal Review Club member Carla Teixeira on behalf of the Ethics section.

References

1. Curtis JR, Vincent JL (2010) Ethics and end-of-life care for adults in the intensive care unit. Lancet 376:1347–1353.
2. Azoulay E, Metnitz B, Sprung CL, Timsit JF, Lemaire F, Bauer P, Schlemmer B, Moreno R, Metnitz P, SAPS 3 Investigators (2009) End-of-life practices in 282 intensive care units: data from the SAPS 3 database. Intensive Care Med 35:623–630.
3. Lautrette A, Darmon M, Megarbane B, Joly LM, Chevret S, Adrie C, Barnoud D, Bleichner G, Bruel C, Choukroun G, Curtis JR, Fieux F, Galliot R, Garrouste-Orgeas M, Georges H, Goldgran-Toledano D, Jourdain M, Loubert G, Reignier J, Saidi F, Souweine B, Vincent F, Barnes NK, Pochard F, Schlemmer B, Azoulay E (2007) A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 356:469–478.
4. Azoulay E, Pochard F, Kentish-Barnes N, Chevret S, Aboab J, Adrie C, Annane D, Bleichner G, Bollaert PE, Darmon M, Fassier T, Galliot R, Garrouste- Orgeas M, Goulenok C, Goldgran-Toledano D, Hayon J, Jourdain M, Kaidomar M, Laplace C, Larche J, Liotier J, Papazian L, Poisson C, Reignier J, Saidi F, Schlemmer B (2005) Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 171:987–994.
5. Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH, Kaufman DC (2008) Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med 36:953–963.
6. Downar J, Delaney JW, Hawryluck L, Kenny L (2016) Guidelines for the withdrawal of life-sustaining measures. Intensive Care Med 42:1003–1017.
7. Robert R, Le Gouge A, Kentish-Barnes N, Cottereau A, Giraudeau B,Adda M, Annane D, Audibert J, Barbier F, Bardou P, Bourcier S, Bourenne J, Boyer A, Brenas F, Das V, Desachy A, Devaquet J, Feissel M, Ganster F, Garrouste-Orgeas M, Grillet G, Guisset O, Hamidfar-Roy R, Hyacinthe A-C, Jochmans S, Jourdain M, Lautrette A, Lerolle N, Lesieur O, Lion F, Mateu P, Megarbane B, Merceron S, Mercier E, Messika J, Morin-Longuet P, Philippon-Jouve B, Quenot J-P, Renault A, Repesse X, Rigaud J-P, Robin S, Roquilly A, Seguin A, Thevenin D, Tirot P, Vinatier I, Azoulay E, Reignier J (2017) Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE Observational Study). Intensive Care Med. doi:10.1007/s00134-017-4891-0.