P0563 - To Trach or Not to Trach: Is A Trial of Extubation Necessary?

Introduction:
When previously healthy children experience sudden catastrophic illness, families can have difficulty understanding what life would be like for a child dependent on technology, such as a tracheostomy tube. Sometimes families are resistant to medically indicated procedures, wanting their child to have every opportunity to prove themselves. Families may want a trial of extubation despite the medical team’s confidence the child will fail. We present a case of family-driven extubation trial.

Case Description:
A 21 month old male with a history of subglottic stenosis presented with influenza-associated respiratory distress. Patient’s early course was uncomplicated. Hospital day five, he acutely decompensated, requiring emergent intubation, found to be in fulminant hepatic failure. He received maximum invasive therapies, including an ICP monitor, plasmapheresis, renal replacement therapy, and ultimately underwent living donor liver transplantation. His course was further complicated by cerebral edema resulting in diffuse ischemic brain injury and severe neurologic impairment with minimal improvement following transplantation. The medical team expressed that based on his neurological exam (including no cough/gag reflex) and MRI findings, the patient’s neurologic injury was severe and irreversible. Multiple multi-disciplinary meetings, including the palliative care team, were held with family. Options proposed included proceeding with tracheostomy or compassionate extubation with withdrawal of life-sustaining measures. A trial of extubation was offered but advised against by the medical team given success was unlikely. The palliative care team aided in facilitation of a second opinion from an outside neurologist and continued discussions with family, ultimately concluding a trial of extubation best aligned with their goals despite the risks. The patient proceeded to extubation, and remains successfully extubated to date.

Discussion:
This case raises the question if a trial of extubation should always be offered when clinically feasible, even if deemed futile by the medical team. The answer may not be clear, given a failed extubation trial can be physically and emotionally distressing, leading to additional suffering and trauma for patient and family, in addition to putting the child at risk. That said, trial of extubation may help families consider next steps (tracheostomy or hospice) and make informed decisions. This case illustrates challenges that arise when family wishes are at odds with providers’ goal to avoid undue suffering. Palliative care can provide a crucial role in identifying a family’s goals, and what they are willing to endure to achieve them.

Conclusion:
Sometimes families must pursue unique avenues to make truly informed decisions. In this case, palliative care’s use of skilled communication, ongoing reassessment of goals of care, and advocacy on behalf of the family’s wishes resulted in a successful trial of extubation and honoring of the family’s values.