Non-invasive ventilation for end-of-life oncology patients – Authors' reply

Correspondence

e201 www.thelancet.com/oncology Vol 14 May 2013

However, as stated in our methods section, all patients had voluntarily chosen to forego all life support and to therefore receive only palliative care, so these were not two distinct populations.

On Azoulay and colleagues’ second point, we agree that further studies are warranted to provide a broader assessment of palliative NIV, with particular emphasis on the experience of family members about the perceived quality of care.I declare that I have no confl icts of interest.

*Stefano Nava, on behalf of the study authorsstefano.nava@aosp.bo.it

Respiratory and Critical Care, Sant’Orsola Malpighi Hospital, University of Bologna, 40138 Bologna, Italy

1 Nava S, Ferrer M, Esquinas A, et al. Palliative use of non-invasive ventilation in end-of-life patients with solid cancer: a randomised feasibility trial. Lancet Oncol 2013; 14: 219–27.

2 Nava S, Evangelisti I, Rampulla C, Compagnoni ML, Fracchia C, Rubini F. Human and fi nancial costs of non-invasive mechanical ventilation in patients aff ected by chronic obstructive pulmonary disease and acute respiratory failure. Chest 1997; 111: 1631–38.

3 Hilbert G, Gruson D, Vargas F, et al. Noninvasive ventilation for acute respiratory failure. Quite low time consumption for nurses. Eur Respir J 2000; 16: 710–16.

4 Curtis JR, Cook DJ, Sinuff T, et al. Noninvasive positive pressure ventilation in critical and palliative care settings: understanding the goals of therapy. Crit Care Med 2007; 35: 932–39.

5 Bausenwein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev 2008; 2: CD005623.

Medicine,4 we believe that the use of NIV in palliative care has a diff erent meaning. We did not mention do-not-resuscitate orders because in Italy, where most of our patients were recruited, we do not have any advanced decisions law.

The non-survivors died after a median of 118 h, and Azad and Franco question the clinical signifi cance of this outcome. However, most of these patients had the time, for example, to say goodbye to their loved ones or to make important fi nal decisions, while being able to speak with reduced respiratory distress.

With respect to the use of morphine—we never questioned its use, but our aim was to relieve dyspnoea, keeping the dose of morphine at the minimum level to avoid any major sensorial impairment. Moreover, we disagree about the use of other pharmacological interventions, since the Cochrane review cited5 by Azad and Franco was concerned with patients without respiratory failure, in whom dyspnoea has a diff erent meaning and mechanisms of action.

Finally, we agree that the data obtained in this study might not currently be generalisable to all palliative care units, although we hope it will become so in the future.

Azoulay and colleagues raise the point that in our study we have mixed patients with a do-not-intubate order with those who received NIV only for symptom relief and comfort.

1 Nava S, Ferrer M, Esquinas A, et al. Palliative use of non-invasive ventilation in end-of-life patients with solid tumours: a randomised feasibility trial. Lancet Oncol 2013; 14: 219–27.

2 Curtis JR, Cook DJ, Sinuff T, et al. Noninvasive positive pressure ventilation in critical and palliative care settings: understanding the goals of therapy. Crit Care Med 2007; 35: 932–93.

3 Azoulay E, Demoule A, Jaber S, et al. Palliative noninvasive ventilation in patients with acute respiratory failure. Intensive Care Med 2011; 37: 1250–57.

4 Azoulay E, Kouatchet A, Jaber S, et al. Noninvasive mechanical ventilation in patients having declined tracheal intubation. Intensive Care Med 2013; 39: 292–301.

Authors’ replyWe thank Arun Azad and Michael Franco, and Elie Azoulay and colleagues, for their comments on our Article.1

Azad and Franco claim that non-invasive ventilation (NIV) is poorly tolerated. However, several studies2,3 have used NIV in various disorders that lead to acute respiratory failure, and the rate of discontinuation due to poor tolerance has always been less than 15%, mainly because the new interfaces and ventilators have substantially improved the synchrony between patient and the ventilator. They also suggest that NIV requires intensive medical and nursing care, but the procedure is not more time-consuming for staff than medical treatment and invasive ventilation, as has been shown in several studies.2,3

Azad and Franco also state that in this scenario, NIV is perceived as a life-sustaining procedure; however, in line with the conclusions of the NIV taskforce of the Society of Critical Care