(357) Compassionate Extubation Practices Within a Community Hospital ICU After Order Set Implementation

Introduction: Compassionate extubation (CE) to allow natural death is often performed in mechanically ventilated patients when recovery is not expected. There is wide variation in practice surrounding CE. We previously studied the CE practices in this ICU prior to order set creation. The purpose of our study was to evaluate implementation of a CE electronic order set.

Methods: This is a single center retrospective observational cohort study of patients who underwent CE in a 9 month convenience sample after CE order set implementation. Patients were identified via EHR query of patients who had an order placed for comfort measures or CE. Demographics, clinical data, and medication use before and after CE were collected by manual chart review. Morphine milligram equivalents (MME) were calculated. Descriptive statistics were used to summarize the data.

Results: Of 59 ICU patients found via EHR query, 9 underwent CE. Of these 9 patients, the median age was 77 (IQR 70-80) and 55% were female. Primary causes of death included sepsis, anoxic brain injury, and stroke. Median Charlson Comorbidity Index was 8 (IQR 4-12). Median SOFA score at time of CE was 11 (IQR 9-14.5). Median length of ICU stay was 48 hours (IQR 24-117). Median time to death after CE was 18 minutes (IQR 10-700). Opioid medications used were morphine, hydromorphone, and fentanyl. Total opioids in the 24 hours prior to CE ranged from 0 to 546 MME (median 12.5, IQR 2.5-30), with 0 to 45.5 MME (median 0, IQR 0-10) given after CE. Non-opioid medications included midazolam, lorazepam, acetaminophen, dexmedetomidine, and propofol. Verbal query of nursing staff revealed at least 1 patient underwent CE without the order set.

Conclusions: In the 9 months following CE order set implementation, 9 patients used the CE order with a median time to death of 18 minutes. Compared to a pre-implementation sample, these patients had a shorter time to death with lower MME. At least one patient underwent CE without use of the order set, which may skew the data. Since ICU populations vary over time, a larger sample size may better characterize these patients. Further research is needed to examine the long-term effects of the order set on clinician comfort with CE management, symptom control, and usability via survey of ICU providers, nurses, and respiratory therapists.