(316) Compassionate Extubation Practices Within a Community Hospital ICU

Introduction: Compassionate extubation (CE) to allow natural death is often performed in mechanically ventilated patients when recovery is not expected. There is wide variation in practices surrounding CE, and the process is not well described in the community setting. The purpose of our study was to analyze CE practices in a community hospital ICU.

Methods: We conducted a single center retrospective observational cohort study of patients who underwent CE in a 9 month convenience sample. Patients were identified through unit nursing leadership records of ICU patients whose code status was changed to comfort measures only. Patients were excluded if they were not intubated or died prior to extubation. Data, including demographics and clinical characteristics, were obtained by chart review. Medication use in the pre- and post-extubation periods were collected. Descriptive statistics were used to summarize the data.

Results: Of 27 ICU patients whose code status was changed to comfort measures only, 13 were compassionately extubated. Among these 13 patients, the median age was 60 (IQR 41-86) and 8 were female (62%). Primary causes of death included sepsis, respiratory failure, hemorrhage, seizure, perforated viscus, chronic organ failure (heart, liver) and overdose. Median Charlson Comorbidity Index at presentation was 6 (IQR 5-8). APACHE II score at time of extubation ranged from 18-51 (median 32, IQR 26-43). Median length of ICU stay was 46 hours (IQR 24-69). Median time to death following CE was 69 minutes (IQR 16-80). The most commonly used opioids included fentanyl, morphine and hydromorphone. Non-opioid medications administered included propofol, dexmedetomidine, midazolam, lorazepam, glycopyrrolate, ondansetron and acetaminophen. The total amount of opioids administered in the 24 hours prior to extubation ranged from 0 to 480 MME (median 37, IQR 11-80), with 0-120 MME (median 5, IQR 2-15) administered after CE.

Conclusions: This study of CE in a community ICU describes diverse pathology and patient characteristics. Our results show a wide range in the medications administered, both prior to and following compassionate extubation. Further study will examine the impact of implementing an electronic health record order set on CE practices.