The increasing use of mechanical ventilation raises concerns of
patient suffering and the societal costs of care. Mechanical ventilation may be lifesaving, but in certain patient cases it may prolong suffering without a clear benefit.
JAMA Internal Medicine
published a study of 635,008
hospitalizations of nursing-home patients with advanced dementia and
severe functional impairment. Between 2000 and 2013, the use of
mechanical ventilation nearly doubled among these patients in some 2,600
cohort hospitals, yet the one-year mortality of ventilated patients
remained above 80%.
‘Mechanical ventilation may be lifesaving, but in certain patient cases it may prolong suffering without a clear benefit.’
Dr. Joan Teno, a
UW Medicine palliative care specialist and the study's corresponding
author, said, "These findings call for new efforts to ensure that the use of
mechanical ventilation is consistent with patient's goals of care and
their clinical condition."
"We want to raise a fundamental policy question of how to improve
end-of-life care, and particularly for very vulnerable populations. We
want caregivers to think and talk about whether this type of care is
achieving the patient's goals and value for society," she said.
In a previous study
Teno co-authored, 96% of family members of similar patients
wanted care to focus on comfort rather than on medical goals such as
survival and organ function.
Teno and colleagues sought to understand the use and outcomes of
mechanical ventilation and its relationship with the increasing numbers
of ICU beds in U.S. hospitals. The study involved patients, age 84, on
average, who were in in a nursing home for 120 days before hospital
admission. They all had advanced-stage dementia and 98% were
The researchers found an association between a hospital's number of
ICU beds and its use of mechanical ventilation: Over time, being
hospitalized at a hospital that increased its ICU beds by 10 was
associated with 6% higher likelihood of mechanical ventilation.
In 2013, the last year of the study, hospitals in the highest-decile
number of ICU beds deployed ventilators to this patient population in
10.6% of cases; by contrast, hospitals in the lowest-decile
number of ICU beds deployed ventilators in 4.5% of cases.
Between those same two decile groups, per-patient reimbursement and
length of hospital stay differed markedly, as well. However, scant
difference was seen in one-year mortality of those patients.
"While it is rarely known in advance that a treatment like
mechanical ventilation in the ICU is futile for a given patient, it
would be sad to think that a vulnerable patient was admitted to an ICU
merely to fill a recently built empty bed which our data suggests may be
happening," said co-author Dr. Vincent Mor, professor of health
services, policy and practice in the Brown University School of Public
Nursing homes can do more to educate families about patients'
prognoses and the benefits and risks of hospitalization, Teno suggested,
and hospitals need to ensure that decisions to employ life-sustaining
interventions reflect patient-informed goals of care. Further, she said,
a national strategic plan is needed regarding regional ICU bed growth.