Goal: Despite significant improvements in neonatal care, the neonatal period continues to be the most vulnerable time for a child’s survival. Withdrawal of life-sustaining invasive ventilatory support (referred to as compassionate extubation, CE) may be recommended by providers and pursued by families when long-term survival with a quality of life that is acceptable to the family is not possible. In our quaternary neonatal intensive care unit (NICU), 60% of deaths in a 12 month period (30 of 50 deaths) occurred following the removal of life-sustaining therapies, primarily after CE. Without a protocol and/or policy, we lack the means to ensure the quality and consistency of the CE process. As a first step in our quality improvement project we assessed baseline practices, attitudes and experiences among NICU nurses and medical providers, with the goal of designing an intervention to promote quality and standardization of CE. Methodology: Online surveys were administered to assess for baseline practices among medical providers and experiences with, and attitudes towards CE among nurses in the NICU. Medical providers (physicians, nurse practitioners, physician assistants) responded to multiple choice questions on anticipated symptom management in vignettes describing patients undergoing CE. Using a level of agreement 5-point Likert scale, nurses who had cared for a patient undergoing CE in the past 12 months were surveyed on their comfort and satisfaction with the process as well as team communication. Results: Forty percent of nurses invited responded to the survey, 40% of whom had been involved in a CE in the previous 12 months at our institution (n= 44 of 110). Eighty-nine percent of nurses who cared for a patient during CE (n = 26) agreed that their patient was comfortable at time of CE and 79% (n = 28) found comfort easy to maintain (Table 1). Fifty-seven percent rated communication with their medical team regarding the CE as “good,” and 12% debriefed with their medical team after CE. There was a 44% response rate among medical providers (n= 32 of 73). In the vignette, medical providers were consistent in their choice of standing and PRN pain medications (Table 2), with wide variability in management of other symptoms during CE. Qualitative responses were also collected and will be analyzed for themes. Discussion: While there appears to be consensus on standing orders for pain, there may be large variation in other aspects of medical management of CE. Chart review will be completed to compare concordance between provider survey responses with actual CE practices in our unit. A notable minority, 21%, of nurses showed concern over maintenance of patients’ comfort, and debriefings were not routine. These results provide context to guide future quality improvement efforts towards optimizing the often challenging event of compassionate extubation.
PRN= As Needed Note: ‘Check All That Apply’ questions allowed for a sum over 100%