Take My Breath Away: Logistical and Social Dynamics of Terminal Weaning from High Flow Nasal Cannula, A Case Report

• Published in: Journal of pain and symptom management Vol. 67; no. 5; pp. e750 - e751
• Main Authors: Chen, Helen, Mondanaro, John F., Adams, Rachel, Reynolds, Max, Uemura, Takeshi
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.05.2024
• ISSN: 0885-3924; 1873-6513
• DOI: 10.1016/j.jpainsymman.2024.02.249

1. Exploring logistical and social dynamics surrounding the decision to discontinue life-prolonging treatment, High Flow Nasal Cannula (HFNC), in a conscious patient. 2. Highlighting the importance of an interdisciplinary support team to patients, their families and medical team members surrounding discontinuation of life-prolonging care. Undergoing terminal weaning from HFNC in a conscious patient requires a coordinated effort from the patient, family, and medical team. This presentation explores the social, cultural and logistical challenges throughout this process. A comprehensive pre-meeting with involved parties on goals of care and post event debriefing and support are essential components of a successful terminal weaning process from HFNC. While palliative extubation from a ventilator is a well documented process during end of life care, the literature on the terminal weaning of a conscious patient from high flow nasal cannula (HFNC) is more sparse. Ms. R, a 72 year-old female with non-small cell lung carcinoma who was hospitalized for interstitial pneumonitis, a course complicated by progressive dyspnea requiring high flow nasal cannula (HFNC). A former medical provider, she was clear about transitioning to comfort focused care immediately, however felt obliged to continue medical management until her family, who recently became aware of her worsening prognosis, was able to come to terms with her decision. Ms. R shared with her family continuing on the current course of therapy including HFNC would be a loss of independence and unacceptable quality of life, which they initially found difficult to accept. The palliative interdisciplinary team explored how Ms. R's Indian culture, medical background, and family hierarchy played roles in her decision making: honoring the multi-generational cultural dynamics of their relationships, was key to help her family understand and respect her autonomy. As Ms. R declined transfer to the palliative care unit with specialized staff, multiple staff logistical debriefings were required. Surrounded by family during weaning, the patient was pre-medicated with lorazepam and hydromorphone, which were available at bedside if needed. Once comfortable, the patient's HFNC (rate 60L/min) was downtitrated and removed. One dose of ativan was administered during frequent monitoring until she died peacefully one hour later. The nursing team, with limited experience in discontinuation of life prolonging treatment, were invited to debrief and receive support from the interdisciplinary team who provided postmortem support to Ms. R's family. This presentation aims to explore unique challenges affecting the patient, family and medical providers when weaning a conscious patient from HFNC. Interdisciplinary Teamwork / Professionalism / Managing Suffering and Distress