(1142) A Therapeutic Dilemma: The Role of Tracheostomy in End-of-Life Care

Introduction: Tracheostomies are often lifesaving in patients requiring prolonged mechanical ventilation. Literature supports early palliative care intervention to align clinical decisions with patient preference, resulting in fewer invasive procedures, including tracheostomies, at end of life. Here we present a case of a terminally ill patient who benefited from tracheostomy despite a poor prognosis.

Description: A 32-year-old male with AIDS, opioid use disorder found unresponsive on the street was intubated by emergency personnel for altered mentation and hypoxemic respiratory failure. Air entry was reduced at the apex with diffuse bilateral coarse breath sounds. Lung imaging revealed cavitary lesions with bilateral consolidation. Sputum culture revealed pseudomonas aeruginosa, pneumocystis carinii and aspergillus; absolute CD4 was 39 mcg/l with CD4% 14. Weaning of sedation was limited by opioid withdrawal syndrome and patient distress, evidenced by restlessness, tachycardia and desaturation. Despite targeting Richmond Agitation Sedation Scale 0 to -2, the patient required deeper sedation. His response to antibiotics by hospital day 14 was poor, with tracheobronchial secretions requiring judicious toileting and continued mechanical ventilation. Goals of care discussion was held with the patient’s family explaining his prognosis and low chance of being weaned off the ventilator. He underwent tracheostomy on hospital day 17. Sedation levels were able to be decreased, allowing him to be awake and calm. He communicated non-verbally with staff and family until he succumbed to IRIS on hospital day 28.

Discussion: Patients with untreated HIV/AIDS and PCP pneumonia have a high mortality rate, up to 80%. The expected short-term mortality for this patient with advanced immunodeficiency and lack of clinical response to treatment was extremely high. He received goal-concordant care with tracheostomy. This facilitated lightening of sedation and the opportunity to be awake and interactive during the final days of his life. Though studies of early palliative interventions, including goals of care conversations, tout avoiding use of tracheostomy at the end of life due to associated financial and emotional burden, this case highlights the humanitarian benefit of tracheostomy for select end-of-life cases.