The Science Journal of the American Association for Respiratory Care

2003 OPEN FORUM Abstracts

SURVEY OF RESPIRATORY THERAPISTS? ATTITUDES AND CONCERNS REGARDING TERMINAL EXTUBATION

David Willms MD, Jodette Brewer RRT, Jack Mullany RRT, *Krista Derolf RRT, Ron Owen RRT, Carmen Kasmauski RRT, Laura Brown RRT, Gary Lanswick RRT

Sharp Healthcare Affiliated Hospitals, San Diego, CA and *Kindred Hospital, San Diego, CA

Background:
Most ICU deaths now occur after a decision to limit or withdraw life support. Withdrawal of ventilatory support, usually with extubation, in a patient with irreversible illness who is expected to die after withdrawal is known as terminal extubation (TE). RTs have a key role in managing mechanical ventilation and frequently participate in TE procedures. Little published information exists regarding RTs' attitudes and concerns about their role in TE, although several studies assessing physician or nursing concerns have been reported.

Methods:
The authors developed a survey instrument containing basic questions about terminal extubation. Surveys were distributed to all practicing RTs at 6 hospitals in San Diego County, CA: 4 general acute care, 1 long-term acute care, and 1 maternal/neonatal hospital. Responses were tabulated and are reported as percentages or mean values where appropriate.

RESULTS:
119 of 180 RTs (66%) returned completed surveys. Respondents had an average of 14.6 years clinical practice, and 50% had the RRT credential. Overall, 96% had personally withdrawn ventilator support at least once, and on average had participated in TE 33 times. Although 73% of RTs were "rarely" or "never" present at the family/staff discussion regarding withdrawal of support, 73% stated they should be included in the process. Respondents estimated a physician was physically present at the bedside during TE in 19% of cases. Only 29% felt an MD should always be present at TE, but 73% felt that the patient's nurse should always be present. Whereas 56% reported that written orders were not always sufficiently explicit to cover TE, 72% expressed a desire for standardized protocols or orders for TE. Of all respondents, 13% had been asked to take a patient off ventilatory support when they felt it was not ethically correct; 9% had sought professional counseling following participation in TE. Most (77%) said they knew where to find emotional support at their institution if needed, and 53% had been informed of their right to decline to participate in TE if they were uncomfortable with it.

CONCLUSION:
The vast majority of RTs participate in TE, but most are not directly involved in the discussions leading to the act of TE; many want to have this involvement in end-of-life-care decision-making. There may be a need for more formal development of specific order sets and protocols for TE. Flexibility in allowing RTs to opt out of TE participation, and access to counseling are important.

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