182 Withdrawal of ventilatory support in conscious patients: evaluating our practice

<h3>Background</h3> Withdrawal of ventilatory support in conscious patients has been consistently challenging in our clinical practice. National guidance for this pertains only to MND. We convened a group of local experts to determine new Trust guidance in 2018, which has been used extensively within LTHT, particularly during COVID and has been adopted by a number of trusts regionally. This Autumn we sought to formally evaluate our practice. <h3>Method</h3> Patients who died on the RSU (respiratory HDU) following the withdrawal of ventilation were identified and at submission, 27 records from April ‘23-April ‘24 had been analysed. Data was collected from electronic medical records including: background; decision to withdraw; communication with patients and families, and the process including medications prescribed and administered. <h3>Results</h3> The most common underlying diagnoses were COPD (10) and neurological conditions (8). 20 patients had non-invasive ventilation withdrawn and 7 were withdrawn from high flow oxygen, with 21 of these having respiratory support started for an acute infection. Discussions about the decision to withdraw (25/27) and the process of withdrawal (16/27) were largely well documented but only 11 had fully documented discussions about the use of medications and 2 about sedation. Of the 23 patients deemed highly dependent on ventilation only 13 were prescribed a syringe driver prior to withdrawal, all at doses lower than recommended in the guidance. Patients needed on average 2.5 PRN doses (0–7) of opioid (total 0–60mg OME) and 2 PRN doses (0–5) of Midazolam (total 0–27.5mg s/c). Time to death was highly variable: seconds- 5 days. Symptoms were deemed fully controlled at death in 15/27. <h3>Conclusion</h3> Use of appropriately dosed syringe drivers may avoid the need for multiple PRN doses, but the late recognition of dying often prohibits their effectiveness. This evaluation supports further use and promotion of the current guidance.