Symptom Management When Non-Invasive Advanced Respiratory Support is Used During End-of-Life Care: A Systematic Review

Abstract

Objectives: to narrate the canon of knowledge around symptom control at end of life for patients using, or having recently used, non invasive advanced respiratory support (NARS) at end of life for respiratory failure. Methods: A systematic review forming a narrative synthesis from a wide range of sample papers from Medline, Embase, CINAHL, Emcare, Cochrane and OpenGrey databases. A secondary search of grey literature was also performed with hand searching reference lists and author citations. The review was undertaken using the ENTREQ checklist for quality. Results: In total 15 studies were included in the synthesis and four themes were generated: NARS as a buoy (NARS can represent hope and relief from the symptoms of respiratory failure), NARS as an anchor (NARS brings significant treatment burden), Impact on Staff (uncertainty over the balance of benefit and burden as well as complex patient care drives distress amongst staff providing care) and the Process of Withdrawal (withdrawal of therapy felt to be futile exists as discrete event in patient care but is otherwise poorly defined). Conclusion: NARS represents a complex interplay of hope, symptom control, unnaturally prolonged death and treatment burden. The literature captures the breadth of these issues but further, detailed, research is required in almost every aspect of practice around end-of-life care and NARS, especially how to manage symptoms at the end of life.

Impact on staff of providing non-invasive advanced respiratory support during the COVID-19 pandemic: a qualitative study in an acute hospital

“…It should be noted that there is currently no literature to support the role of NARS as effective symptom relief in COVID-19 and only limited evidence in COPD. 8 …”

“…These represent acts of omission, acts that are not undertaken by healthcare workers due to the environment in which they are working, and this led participants to feel as if their care was lacking. It should be noted that there is currently no literature to support the role of NARS as effective symptom relief in COVID-19 and only limited evidence in COPD 8…”

“…Despite this, there are little data or guidance for clinicians caring for these patients at the end of life—perhaps because of the lack of research into symptom control in this area of care 7 8…”

The Use of Mechanical Ventilation Support at the End of Life in Motor Neurone Disease/Amyotrophic Lateral Sclerosis: A Scoping Review

“…There is currently little published evidence about what it is like for patients using mechanical ventilation to die, or to have ventilation withdrawn, what informs this decision, or how patients and families are supported throughout the experience [ 19 ]. Yet, the use of mechanical ventilation across Europe and North America is increasing in a range of conditions, including chronic obstructive pulmonary disease (COPD), obesity-related respiratory failure, neuromuscular diseases, including motor neurone disease [ 20 ], and, presently, COVID-19-related respiratory disease [ 21 , 22 ].…”