Around one-third of patients over the age of 65 who are placed on mechanical ventilation (intubation) die in the hospital, and only a quarter are discharged home, according to a June 22, 2018, article in the New York Times. More than three-fifths (63%) of intubated patients who survive in the hospital are discharged somewhere other than home, such as a skilled nursing facility, according to a study cited by The Times. This is important, the Times article said, because older patients "so often declare they'd rather die than spend their lives in nursing homes." The data are leading some doctors to wonder whether breathing tubes should be used as often as they are. Intubation is indeed lifesaving, said a doctor quoted in the article, but patients "sometimes have values and preferences beyond just prolonging their lives." The doctor described seeing patients who had been on ventilators for days, and often hearing a daughter say, "She would never have wanted this." A study cited by The Times showed that most patients with do-not-intubate or comfort-care-only orders who received noninvasive ventilation survived to discharge and avoided intensive care. The doctor noted that he never received any training in how to talk to patients or their families about intubation. Another physician quoted in the article says that he gently explains to patients and families that it is possible the patient will die during intubation; while he sets up the intubation, he encourages them to "spend time sharing words of comfort, reassurance and affection." Without that pause before the procedure, the doctor said, he feels he might have "stolen the last words from patients."
HRC Recommends: Effective policies, procedures, and staff education involving end-of-life issues, such as do-not-intubate orders, may help avoid conflict among patients, surrogates, and treating physicians. Knowledgeable risk managers should provide resources and facilitate processes for resolving conflicts and provide education and support to patients' surrogate decision makers. Organizations need to be familiar with statutes that address these issues in their jurisdictions and should create procedures to guide staff involved in decision making about withdrawal of life-sustaining treatment.