“Use of noninvasive ventilation (NIV), such as continuous or bilevel positive airway pressure, has increased in select populations of patients with respiratory failure (eg, those with acute exacerbations of chronic obstructive pulmonary disease [COPD] or congestive heart failure [CHF]) because of improved outcomes (ie, increased survival, shorter length of stay, and lower costs) compared with IMV [invasive mechanical ventilation]. As a result of the expanded use of NIV, use of IMV among these populations has substantially decreased over time.
Use of NIV to improve survival has been established; however, its use has also been suggested to achieve palliation in persons with terminal illness. Although evidence is limited, under palliative circumstances, NIV may be introduced on a trial basis to reduce dyspnea and respiratory distress while allowing patients and families more time to address goals and finalize affairs. Compared with high-flow or supplemental oxygen therapy, NIV has been associated with reduced dyspnea and morphine needs among patients with cancer.
[..] We selected a 20% random sample of Medicare fee-for-service beneficiaries aged 66 years or older who had a hospital admission in the last 30 days of life and died between January 1, 2000, and December 31, 2017. In addition, within this cohort, we identified 4 subcohorts of Medicare beneficiaries. A diagnosis of dementia was ascertained using the primary or the first 9 secondary admission diagnosis codes for hospitalization from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). The other subcohort diagnoses (CHF, COPD, and cancer) were identified using the primary admitting diagnosis codes from ICD-9-CM or ICD-10-CM. [..] Patients with a primary admitting diagnosis of cardiac arrest or with preexisting tracheostomy were excluded because of ventilatory requirements. The cohort included decedents in hospitals that provided 5 or more beneficiary hospitalizations per year in the last 30 days of life and 1 hospitalization per unique beneficiary.
[..] Among these decedents, the top 3 admitting diagnoses were pneumonia or sepsis (n = 525,523 [21.3%]), cancer (n = 237,335 [9.6%]), and CHF (n = 155,273 [6.3%]). [..] Overall, IMV was used in 401,419 of 2,470,435 decedents (16.3%), NIV in 90,700 decedents (3.7%), and both IMV and NIV in 25,689 decedents (1.0%). Among decedents who received NIV, 51,038 (56.3%) had an ICU stay.
From 2000 to 2017, an almost 9-fold absolute increase in NIV use from 0.8% to 7.1% occurred, whereas IMV use increased slightly from 15.0% to 18.5% and was twice as common as NIV use.
[..] In all subgroups of CHF, COPD, cancer, and dementia diagnoses, decedents who received NIV vs IMV had lower rates (expressed as % of hospitalizations or hospice enrollees) of in-hospital death (50.3% [95% CI, 49.3%-51.3%] vs 76.7% [95% CI, 75.9%-77.5%]) and hospice enrollment in the last 3 days of life (57.7% [95% CI, 56.2%-59.3%] vs 63.0% [95% CI, 60.9%-65.1%]) as well as a higher rate of hospice enrollment (41.3% [95% CI, 40.4%-42.3%] vs 20.0% [95% CI, 19.2%-20.7%]). Decedents from CHF and COPD subgroups with NIV use had similar end-of-life care (in-hospital death, hospice enrollment in the last 3 days of life, and hospice enrollment) (CHF vs COPD, in-hospital death: 49.0% [95% CI, 47.3%-50.6%] vs 43.6% [95% CI, 40.7%-46.5%]; hospice enrollment in the last 3 days: 40.2% [95% CI, 38.6%-41.8%] vs 42.5% [95% CI, 39.6%-45.4%]; and hospice enrollment: 24.2% [95% CI, 22.9%-25.6%] vs 23.4% [95% CI, 21.0%-26.0%]). Meanwhile, decedents from cancer and dementia subgroups with NIV use had the following end-of-life care (in-hospital death: 60.8% [95% CI, 58.0%-63.5%] vs 50.1% [95% CI, 48.5%-51.8%]; hospice enrollment in the last 3 days: 38.9% [95% CI, 36.2%-41.7%] vs 43.0% [95% CI, 41.4%-44.6%]; and hospice enrollment: 24.3% [95% CI, 21.9%-26.8%] vs 24.0% [95% CI, 22.6%-25.4%]).
[..] For patients with CHF and COPD, use of NIV may improve outcomes and avoid the use of IMV. In this study, the finding of the rapid growth of NIV use among persons with cancer and dementia without reciprocal decreases in IMV use raises more questions than answers. Use of NIV may be associated with agitation and distress for patients with cancer and dementia at the end of life, prolonging their death. Given the rapid growth in NIV use, further research is needed to examine the goals of this therapy and whether it achieves those goals.
[..] The strongest evidence of the benefit of NIV exists among patients with acute exacerbations of CHF or COPD. The potential for improved outcomes in these patients likely explains the increases in NIV use and the reciprocal decreases in IMV use that we observed. However, outside of these indications (CHF and COPD), favorable outcome of NIV use in patients with hypoxemia was not established in randomized clinical trials unless trials of patients with CHF or COPD were included; therefore, the rapid growth in NIV use that we observed among persons with cancer and dementia is concerning. In addition, NIV necessitates a higher level of care than provided in a hospital ward because of the closer monitoring required; therefore, the recommendation is to implement NIV in an ICU or a high-dependency unit (eg, ICU step-down unit) in hospitals that have these units. Other obstacles for NIV include the contraindications in patients who are agitated, are uncooperative, have substantial airway secretions, or are unable to protect their airway. Approximately 22% of the present cohort may have had NIV failure, a rate that was comparable to the one-quarter to one-third of patients who reportedly had NIV failure and required endotracheal intubation and IMV, which has been associated with increased risk of death.
[..] The rapid growth in NIV use among patients with cancer and dementia may represent another example of overtreatment or low-quality care (ie, care in which the risks outweigh the benefits) at the end of life. Given the potential for substantial patient and family burden, costs, and health care resources associated with NIV without demonstrable benefit, and even the potential to introduce harm, NIV use among patients with cancer and dementia at the end of life warrants a thorough discussion about the goals of therapy between clinicians and patients and their health care proxies.
As an alternative explanation to overtreatment, NIV use at the end of life has been suggested based on limited evidence for palliation on a trial basis to help alleviate respiratory distress and provide patients and families time to address goals.
[..] In this study, evidence that supported the palliative intent of NIV, based on measures of end-of-life care, was lacking given that in-hospital death, hospice enrollment, and late hospice enrollment were similar for patients with cancer and dementia who received NIV compared with patients with CHF or COPD who received NIV. Furthermore, we observed worse rates of hospice enrollment among patients with cancer and dementia who received NIV than were previously reported among Medicare fee-for-service beneficiaries at the end of life, which was not consistent with palliative intent. Although palliative use of NIV at the end of life may offer some value to patients with advanced cancer, based on limited evidence, inherent differences among patients with dementia deserve consideration.
[..] Given the rapid growth, the potential for patient harm and distress, and the substantial health care resources associated with NIV use, further research is warranted to evaluate its outcomes and to inform discussions about the goals of this therapy between clinicians and patients and their health care proxies so that they can make patient-centered choices.”
Full article, Sullivan DR, Kim H, Gozalo PL et al. JAMA Internal Medicine 2020.10.19