Tuesday, November 29, 2005

Respiratory Therapists and Terminal Extubation

As a palliative medicine physician involved in terminal extubations in the intensive care unit, I always encourage a team approach. During my residency I learned very quickly to include the respiratory therapist (RT) in making the plan to terminally extubate someone. I always ask the RT and the bedside nurse before we terminally extubate a patient two questions: Are you OK with this course of action? Do you have any suggestions to improve the care around the extubation? In addition I review the orders and the planned way we will extubate. I also stay with the patient before during and after the extubation to ensure quick access for symptom control measures.

After talking to a RT colleague of mine, I did a lit search on their involvement in the process and ran across this survey of RT attitudes and concerns regarding terminal extubation in the journal of Respiratory Care (free full text here). Since the RT and not the nurse or the physician is the person who actually extubates and enacts the order there may be issues of stress that are not always openly addressed. A one-page questionnaire was given to 183 RT's at 6 facilities in San Diego. Some of the more interesting findings were:

On average, respondents had been involved in terminal extubation on 2.2 occasions (range 0-12) within the last year, and 33 times in their entire career.
The RT's were rarely included in the discussion with family or patient at the time of the decision. The estimates of physician presence averaged 18.6% (range 5.5-66%), and only 29% of RT's felt the attending physician should be present at time of terminal extubation. But they did find a correlation between the RT's perception of need for attending presence and how often the RT's estimated they were present. At the facility with 66% estimate of MD presence, more RT's felt their presence was important. This fact demonstrates how much the difference in ICU cultures can influence EOL care.

There are many more places this survey could go, particularly surveying hospitals with a strong or weak palliative medicine presence.

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