Withdrawal of Ventilatory Support at Home on Hospice.

CONTEXT: When ventilatory support is withdrawn in an intensive care unit (ICU), the place of death for most patients is the hospital. However, the majority of terminally ill patients prefer to die at home. Few articles have addressed taking adult mechanically ventilated patients home from the ICU for withdrawal of ventilatory support (WVS).

OBJECTIVES: To determine the outcomes of a protocol-driven program of WVS in the home under hospice care.

METHODS: A retrospective chart review of 14 consecutive patients who had WVS at home. All subjects were mechanically ventilated ICU patients referred to hospice with a request for WVS to be performed in the patient's home. A protocol/checklist guided care. Medical records were reviewed to obtain demographic and medical information, particularly for duration of mechanical ventilation, the use of premedication, level of consciousness at the time of WVS, symptoms following WVS, pharmacologic measures used for symptom control after WVS, and survival time after WVS.

RESULTS: At the time of WVS, five patients were awake or arousable and nine were stuporous or comatose. Ten patients required no medication before WVS; only four required medications for symptom control after WVS. Median survival after WVS was 18.15 hours. In all cases, symptomatic control was judged to be excellent.

CONCLUSION: Successful WVS and a natural death at home is possible with logistic support from the hospice organization and the expertise of the hospice team, guided by a comprehensive protocol/checklist.