Terminal withdrawal of mechanical ventilation at a long-term acute care hospital: comparison with a medical ICU.

Background: Failure to wean from prolonged mechanical ventilation (MV) is common in long-term acute care hospitals (LTACHs), but the process of terminal withdrawal of MV in LTACHs is not well described. We compared terminal withdrawal of MV at an LTACH with that in a medical ICU (MICU). Methods: A retrospective medical chart review was done of all patients undergoing terminal withdrawal of MV in an LTACH (n 30) and in a MICU (n 74) over a 2-year period. Results: The decision to withdraw MV was more likely initiated by patient or family in the LTACH and by medical staff in the MICU (p < 0.0001). Social workers, pastoral care, and hospital administration were more likely to participate in the withdrawal process at the LTACH compared with the MICU (p < 0.05). Time from initiation of MV to orders for do not resuscitate, comfort measures only, or withdrawal of MV was significantly greater in the LTACH (weeks) compared with the MICU (days) (p < 0.05). The dose of benzodiazepines given during the final 24 h of life was greater in the MICU as compared with the LTACH (p < 0.05). Narcotic and benzodiazepine use in the hour before or after withdrawal of MV did not differ between the two groups. COPD and pneumonia were the most common causes of death among patients undergoing withdrawal of MV at the LTACH, as opposed to septic shock in the MICU (p < 0.05). Conclusions: Terminal withdrawal of MV in the LTACH differs from that in the MICU with regard to decision making, benzodiazepine use, and cause of death. (CHEST 2009; 136:465–470) Abbreviations: CMO comfort measures only; DNR do not resuscitate; LTACH long-term acute care hospital; MICU medical ICU; MV mechanical ventilation