Mechanical ventilation is a life support treatment. A ventilator is a machine that helps patients breathe when they are not able to breathe enough on their own. The ventilator is also called a respirator or breathing machine. Most patients who need support from a ventilator because of a severe illness are cared for in a hospital’s intensive care unit (ICU). Patients who need a ventilator for a longer time may be in a regular unit of a hospital, a rehabilitation facility, or cared for at home.
A ventilator forces the lungs to work. The ventilator is connected to either a mask (noninvasive ventilation) that the patient wears or the patient is intubated, which involves putting a tube down the throat into the trachea or windpipe. Because this tube can be quite uncomfortable, people are often sedated with very strong intravenous medicines. Restraints may be used to prevent the patient from pulling out the tube. If the person needs ventilator support for more than a few days, the doctor might suggest a tracheotomy, sometimes called a “trach”. This tube is then attached to the ventilator. This is more comfortable than a tube down the throat and may not require sedation. Inserting the tube into the trachea is a bedside surgery. A tracheotomy can carry risks, including a collapsed lung, a plugged tracheotomy tube, or bleeding.
If a patient has very severe breathing problems or has stopped breathing, a ventilator may be needed. This is the case for patients with advanced heart, lung, kidney, or liver disease, metastatic cancer, advanced frailty, and advanced neurodegenerative disease (e.g., Dementia, Parkinson’s Disease, ALS). This is also the case in severe infections like influenza and coronavirus.
Older patients, especially those with advanced illness and/or frailty stay on a ventilator longer and have a worse outcome. It may be difficult to wean older patients from the respiratory support a ventilator provides.
The current DOH MOLST Form includes “Instructions for Intubation and Mechanical Ventilation” that outline the medical order chosen as a result of a well-informed shared-decision making process.
There are 3 choices:
Survival among mechanically ventilated patients depends not only on the factors present at the start of mechanical ventilation, but also on the development of complications and patient management in the intensive care unit.
Patients with advanced illness and/or advanced frailty are at particularly high risk. These are the patients who are appropriate for MOLST and should be offered the opportunity to engage in shared medical decision-making that is well informed, using the 8-Step MOLST Protocol.
For example, cirrhotic patients requiring mechanical ventilation have an extremely poor prognosis, and in patients requiring vasopressors, having a history of decompensation, sepsis or low albumin, mortality is higher. Clinical variables should be considered in the medical management of these patients and provide physicians with a formula to predict the probability of mortality.
The use of noninvasive ventilation (NIV) as first-line supportive therapy for acute respiratory failure (ARF) is increasing in the intensive care unit. The reduced invasiveness of this technique in selected populations of critically ill patients can lead to better outcomes than with endotracheal intubation. NIV can reduce the need for intubation and decreases mortality during acute-on-chronic respiratory failure (AOC), cardiogenic pulmonary edema (CPE), and de novo ARF in immunocompromised patients. The choice of NIV aims to avoid complications, particularly in fragile patients. Patients aged 80 years or older, also referred to as “very old patients,” are potentially “good candidates” for a less invasive management.
Noninvasive ventilation (NIV) is frequently used for the management of acute respiratory failure (ARF) in very old patients (≥ 80 years), often in the context of a do-not-intubate order (DNI). NIV is associated with a lower risk of pneumonia and death than is endotracheal intubation.
A trial of life-sustaining treatment may be ordered if the physician or nurse practitioner or physician assistant (as of June 17, 2020) agrees it is medically appropriate. A trial is used to determine if there is benefit to the patient and is based on the patient’s current goals for care. If a life-sustaining treatment is started but turns out not to be helpful and does not meet the patient’s goals for care, the treatment can be stopped.
A trial is patient-specific. Be detailed in describing the goals and document the details of the trial in “Other Instructions”.
There is no medical, legal or ethical distinction between withholding and withdrawing life-sustaining treatment. A decision to withdraw ventilator support should be based on the patient’s goals. If there was a distinction, patients would not opt for a trial of therapy.
Much is being written about the appropriate use of ventilators. Ethical principles should guide the allocation of scarce resources, particularly ventilators during COVID-19. State laws, regulations and guidance vary and may not align with these principles.
Reviewing current MOLST orders with the patient, or their health care agent or surrogate if they lack capacity is an important step being taken now to deal with a potential surge. For those who do not want to be hospitalized or placed on a ventilator, an appropriate care plan is needed.
If there is a shortage of ventilators, large populations of patients from access to scarce intensive care unit (ICU) resources. Decisions should not be made based on patient race, ethnicity, religion, insurance, intellectual/developmental disabilities (I/DD) or other unrelated issues.
DOH and the New York State Task Force on Life and the Law released updated guidelines for allocating ventilators during an influenza pandemic in New York in 2015. Guidelines are under review amid COVID-19. Thus far in NY, there is no evidence that the legislature or the governor intend to delegate reallocation decisions to physicians. In the interim, see current guidelines:
Patients appropriate for MOLST may wish to change their preferences for respiratory support based on their goals for care.
Preferences may change as medical conditions, health status and prognosis worsen over time.
The same may be true during the COVID-19 crisis. It is important to make time to review and renew MOLST now. The discussion must be patient-centered, honest and compassionate, considering the patient’s medical condition, health status, prognosis and goals for care.
Effective communication skills are essential. Read more about how to have this crucial conversation.
For those who do not want to be hospitalized or placed on a ventilator, an appropriate care plan is needed.
Submit your email address to receive New York's MOLST Update.
The MOLST Update is a Newsletter dedicated to providing up-to-date information on advance care planning, MOLST and eMOLST.