Managing patients with COVID-19 rapidly deteriorating to end of life when CPAP/NIV is their ceiling of care
Patients with COVID-19 can deteriorate very rapidly to end of life, and a strategy for managing these patients to avoid distress when dying comes in the form of the COVID-19 Palliative Care Guidance (linked below). This is one of two Palliative Care Guidelines created to support frontline teams, and follows four steps to determine the patients ceiling of treatment, achieve sedation and alleviate symptoms, and if part of their end of life plan, wean from CPAP/NIV.
This guidance is only intended for the specific situation of rapid deterioration over short time period (as short as 30-60 minutes) towards end of life and not for more gradual deterioration where a different approach to symptom control is required. Guidance for patients at the end of life who are not within these specific scenarios is available via this link.
Step 1
Determine the patient’s ceiling of treatment and priorities of care, and the patient and their family understand that if they were to deteriorate, the patient’s comfort and symptom control would be prioritised.
Step 2
In this specific scenario, with the patient rapidly deteriorating over minutes to hours to end of life, administer medicines with the goal of care being to induce sedation and relieve agitation and distress over a short period of time (10-15 minutes), aiming for no response to voice or light glabellar tap. The doses found on the guideline (attached below) may seem higher than your usual practice for symptom control, but these are appropriate and proportionate to the goal of care.
Step 3
Once sedation is achieved and the goal is to remove CPAP or NIV as part of the end-of-life plan, the CPAP pressure can be weaned down by 50%, or if the patient was on NIV (BIPAP) the IPAP pressure can be weaned down by 50%. Wait 10 minutes to make sure the patient has not become distressed, and wean off CPAP or NIV, on to oxygen therapy (if appropriate). Additional doses of medication will be required to maintain the level of sedation.
Step 4
Maintain sedation using repeated doses of medication. If appropriate, a continuous subcutaneous infusion could be considered but be mindful that this would take at least 4 hours to have a peak effect.
Managing patients with COVID-19 rapidly deteriorating to end of life when CPAP/NIV is their ceiling of care
Patients with COVID-19 can deteriorate very rapidly to end of life, and a strategy for managing these patients to avoid distress when dying comes in the form of the COVID-19 Palliative Care Guidance (linked below). This is one of two Palliative Care Guidelines created to support frontline teams, and follows four steps to determine the patients ceiling of treatment, achieve sedation and alleviate symptoms, and if part of their end of life plan, wean from CPAP/NIV.
This guidance is only intended for the specific situation of rapid deterioration over short time period (as short as 30-60 minutes) towards end of life and not for more gradual deterioration where a different approach to symptom control is required. Guidance for patients at the end of life who are not within these specific scenarios is available via this link.
Step 1
Determine the patient’s ceiling of treatment and priorities of care, and the patient and their family understand that if they were to deteriorate, the patient’s comfort and symptom control would be prioritised.
Step 2
In this specific scenario, with the patient rapidly deteriorating over minutes to hours to end of life, administer medicines with the goal of care being to induce sedation and relieve agitation and distress over a short period of time (10-15 minutes), aiming for no response to voice or light glabellar tap. The doses found on the guideline (attached below) may seem higher than your usual practice for symptom control, but these are appropriate and proportionate to the goal of care.
Step 3
Once sedation is achieved and the goal is to remove CPAP or NIV as part of the end-of-life plan, the CPAP pressure can be weaned down by 50%, or if the patient was on NIV (BIPAP) the IPAP pressure can be weaned down by 50%. Wait 10 minutes to make sure the patient has not become distressed, and wean off CPAP or NIV, on to oxygen therapy (if appropriate). Additional doses of medication will be required to maintain the level of sedation.
Step 4
Maintain sedation using repeated doses of medication. If appropriate, a continuous subcutaneous infusion could be considered but be mindful that this would take at least 4 hours to have a peak effect.
Resources
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COVID-19 Palliative Care Guidance: CPAP or NIV as ceiling of treatment
Symptom control in rapidly deteriorating patient with COVID-19 on NIV or CPAP as their ceiling of treatment.
