Critical care clinics
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Critical care clinics · Apr 2007
ReviewDiscontinuation of mechanical ventilation at end-of-life: the ethical and legal boundaries of physician conduct in termination of life support.
End-of-life care in the ICU generally encompasses both the withholding and withdrawal of life support and the administration of palliative care. There is little practical distinction in the specific technology or life-support modality that is limited or removed with respect to the subsequent medical, ethical, or legal analysis. The important ethical issues pertinent to end-of-life care in the ICU at the point-of-life support discontinuation are: (1) the distinction between allowing patients to die in accordance with their wishes and causing them die, (2) the fine line between respecting a patient's wish to die with dignity and control and the risk of subsequent allegations of euthanasia or physician-assisted suicide, and (3) the adjunctive use of medications that simultaneously provide comfort but also may hasten death. The medical and legal issues are summarized, and an algorithm for the discontinuation of mechanical ventilatory support at the end of life is presented.
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Critical care clinics · Apr 2007
Therapist driven protocols: a look back and moving into the future.
Therapist-driven protocols have been shown to decrease the duration of mechanical ventilation, reduce cost, length of stay, and improve the rate of weaning when compared with physician-directed weaning. This article describes protocols used at the author's institution. It describes how the respiratory therapy service interacts with other services within the hospital to provide the optimal outcome for the patient.
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Approximately 20% of all mechanically ventilated patients fail their first attempt to wean. Prolonged mechanical ventilation increases morbidity, mortality, and costs. No single weaning parameter predicts patient ability to wean. Weaning studies suggest that daily trials of spontaneous breathing for appropriate patients assured by standing protocol and driven by respiratory care practitioners and/or nurses improve the weaning process and patient outcome.
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The primary goal of ventilator support is the maintenance of adequate, but not necessarily normal, gas exchange, which must be achieved with minimal lung injury and the lowest possible degree of hemodynamic impairment, while avoiding injury to distant organs such as the brain. Modes of MV are described by the relationships between the various types of breaths and by the variables that can occur during the inspiratory phase of ventilation. There are two basic modes of ventilation: ventilation limited by a pressure target and ventilation limited to the delivery of a specified volume.
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Critical care clinics · Jan 2007
ReviewMoving our critically ill patients: mobility barriers and benefits.
Diagnosis and resuscitation for critically ill patients have improved in the last 25 years, and survival has also increased. With improvements in mortality, the field of critical care has seen increased opportunities to improve posthospital quality of life for survivors of critical illness. This article focuses particularly on how mobilization may improve quality of life for patients.