Palliative care and circumstances of dying in German ALS patients using non‐invasive ventilation

Abstract

Non-invasive ventilation (NIV) is known to improve quality of life and to prolong survival in amyotrophic lateral sclerosis (ALS) patients. However, little is known about the circumstances of dying in ventilated ALS patients. In the light of the debate on legalizing euthanasia it is important to provide empirical data about the process of dying in these patients. In a structured interview, 29 family caregivers of deceased ALS patients were asked about their own and the patient's attitude toward physician-assisted suicide (PAS) and euthanasia, circumstances of dying, and the use of palliative medication. Quantitative and qualitative content analysis was performed on the data. Non-recurring suicidal thoughts were reported by five patients. Three patients and seven relatives had thought about PAS. Seventeen caregivers described the patients' death as "peaceful", while choking was reported in six bulbar patients. In final stages of dying, the general practitioner (GP) was involved in the treatment of 10 patients, with palliative medication including sedatives and opiates being administered in eight cases. In conclusion, in contrast to the Netherlands, where 20% of terminal ALS patients die from PAS or euthanasia, only a small minority of our patients seems to have thought about PAS. The legal situation in Germany (where euthanasia is illegal), a bias due to the selection of NIV patients as well as a high percentage of religious patients and those with good levels of social support from family and friends, might account for this. Most of our patients died peacefully at home from carbon dioxide narcosis, but choking was described in some bulbar patients. Thus, palliative care, especially the use of opiates, anxiolytics and sedatives should be optimized, and the involvement of GP should be strongly encouraged, especially in bulbar patients.

BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults

“…Once patient comfort is assured, it is suggested that mandatory ventilation is withdrawn and PS reduced to zero over 5–10 min. Kuhnlein et al 289 conducted structured interviews with 29 families regarding the circumstances of dying in MND patients receiving NIV. Seventeen caregivers described the final stages and eventual death as ‘peaceful’.…”

Culture and End of Life Care: A Scoping Exercise in Seven European Countries

“…ADs was a well-covered theme. Studies explored awareness of ADs, use and compliance [138], [144], [145], [146], [147], [148], [149], [150], [151], [152] and desired level of bindingness [150], [153], [154], [155].…”

Withdrawal of Invasive Home Mechanical Ventilation in Patients with Advanced Amyotrophic Lateral Sclerosis: Ten Years of Danish Experience

“…We believe therefore that to be ethically the ethically justifiable, the termination of ventilatory treatment requires the induction of deep sedation, and this is consistent with a previous study. 5 We have described our use of morphine and sedatives in the hope of inspiring others but as Kü hnlein and colleagues 19 argue it is important to find further empirical data about the process of dying in these patients.…”