Review was sought in the medical Intensive Care Unit for an 87-year-old female with a history of aplastic anaemia, a recent diagnosis of acute leukaemia, pneumonia and desaturation, who had been started on non- invasive ventilation with Fi02 of 0.5 and PEEP of 5. Investigations were suggestive of pancytopenia, though parameters of renal function appeared to be unaffected. Her lactate level was 0.6.
De-escalation to NIV on BiPAP mode was planned, and the family had expressed their preference for non-escalation to Mechanical ventilation and DNACPR. The NIV was removed for the purpose of feeding, and she was able to talk and respond. The family requested non-disclosure of diagnosis citing her advanced age and the distressing nature of the new cancer diagnosis.

The Palliatrist appeared torn between respecting family preferences and allegiance to patient autonomy.

How to assess capacity in this setting?
Four important pillars central to capacity determination have been identified.
Understanding – ability to understand that she is unwell, support for breathing is required, options involved, likely outcomes and the possibility of death if she declines it.
Retention – ability to retain information in order for her to make a decision. May require prompts in order to aid retention.
Reasoning – able to reason that allows value-based engagement with the information supplied.
Communicate – able to communicate her decision.

The following confounders might interfere with her ability to understand the information provided to her – hypercapnia and hypoxia on arterial blood gas analysis, delirium (CAM ICU may be used), ongoing drugs such as opioids and benzodiazepines and sepsis.

In the event that the patient has capacity, how should disclosure be approached?
An attempt should be made to separate disclosure from the diagnosis.
Start by enquiring how much she would like to know. Some patients would prefer to know all the details, while others would prefer that their families decide for them. The approach of the palliatrist needs to focus upon disclosing information relevant to the decision under review.
If she says that she wants to know more, disclose what she would like to know.
If she delegates decision-making to her family, that would signal resolution of collusion.
She may be told that she is unwell and requires support for breathing, followed by providing her with the option for breathing support with intubation. The information about poor outcomes related to intubation needs to be discussed in order for her to make an informed choice.
The contents of the discussion need to include information relevant to her present condition.

At the same time, it may be advisable to inform the family members that the team will not force any information, will not lie or offer false hope and will ask her what she would like to know first.

What information do the NIV parameters provide about the patient’s condition?
Presence of hypoxaemic respiratory failure with minimal pressure support only. In immunocompromised patients, NIV has shown no mortality-related benefit over standard oxygen.
While the NIV is expected to be keeping her comfortable by reducing the work of breathing, it is important to understand that the use of a tight-fitting mask, restriction to feeding and speaking might in itself pose a challenge to its continuation and might appear to be distressing. The point at which NIV becomes a burden in itself needs to be arrived at in discussion with the family.

How would NIV failure and dependence be defined in this situation?
NIV failure is characterised by worsening physiological parameters despite continuation.
Worsening oxygenation, falling PaO2 or SpO2 despite rising FiO2.
Persistent tachypnoea or rising respiratory rate and use of accessory muscles.
A new rise in PaCO2 or acidosis
Falling GCS or delirium
Haemodynamic instability
Inability to tolerate the mask

Late deterioration (over 48 hours) after an initial improvement carries the worst prognosis.
HACOR score – Heart rate, acidosis, consciousness, oxygenation and respiratory rate.
NIV failure should trigger initiation of comfort-directed therapy with an expected survival of hours to days only.

Dependence on NIV or a failure to wean implies that while the acute illness might have stabilised, she is unable to breathe without the support of non- invasive ventilation.

If cessation of NIV is to be interpreted as withdrawal of treatment, the process involves primary and secondary tumour board with intimation of the Magistrate, unless physiological failure has been documented, for which there appears to be a lack of judicial precedent. Existing judgements also refer to mechanical ventilation and life-sustaining treatment, without including a specific reference to non-invasive ventilation. The ISSCM/IAPC position statement treats stopping non- beneficial treatment as ordinary medical practice, but whether this can withstand legal challenge by an informed family has not been decided in a court of law.

How does this contrast with existing practice in the UK?
As per the ruling of Airedale NHS Trust v Bland [1993], withholding and withdrawing treatment are considered legally equivalent, and stopping treatment that might not be in the patient’s best interest does not constitute an act that is punishable by law. Recourse to the court of law is not required if the clinicians and family remain in agreement (Re Y [2018] UKSC 46).

The patient deteriorated the next day, developed carbon dioxide retention, and was unable to remove the NIV. The family complained of difficulty in feeding her and her discomfort with the mask.
In the event that there is deterioration which meets the criteria for early NIV failure, there might be a need to optimise the NIV settings first.
The titration of IPAP to pH, PaCO2, respiratory rate and comfort might be considered within the ceiling.
Checking for the mask fit, leak, and asynchrony might also be in order.
Drugs, retained secretions, fluid overload, new effusion or pneumothorax might also act as likely contributors.
Pre-defining a short window during which time these parameters may be optimised, and defining pre-defined criteria such as worsening pH and PaCO2 or declining consciousness as indicators of NIV failure might be part of the goals of treatment.

What is the role of palliative sedation in this setting?
Palliative sedation is indicated for a refractory symptom, that is, breathlessness, when death is expected within hours to days and when other measures have failed.

Comfort-focused measures titrated to symptom control, including PRN doses of Morphine and midazolam, and consideration of continuous infusion when repeated bolus doses are required, might represent a starting point that indicates an understanding of the poor prognosis, the irreversible nature of her condition and a transition towards comfort-focused care.

Disclaimer

Artificial intelligence tools have been employed for conceptual engagement and language refinement. They do not replace critical scholarship, clinical experience, or editorial judgment. Final responsibility for all interpretations, factual accuracy, originality of synthesis, and the quality of the published material rests entirely with the Founder and Editor.