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Limitations of High Flow Nasal Cannula at End of Life

Rationale Many patient with end-stage fibrotic lung disease die in the hospital due to dependence on High Flow Nasal Cannula (HFNC), not available at home. Despite available technical maturity, HFNC is not sufficiently available due to size and portability, energy requirement and oxygen (O2) capacity. This has become particularly problematic during the current Covid-19 pandemic, when many had to die alone in hospital due to these constraints. ObjectiveThe objective of this investigation was to appreciate the number of patients who die in hospital on comfort care, who could benefit from HFNC at home to support person-centered care (self-determination, family involvement, comforts of home) at end of life (EOL). MethodsWe collected data from a convenience sampling of patients who received care at a 449-bed acute-care community hospital in Southern California between June 2020 and June 2021. Data from this retrospective review of the electronic health record included demographics (age, gender, BMI and ethnicity). Other variables collected were length of stay (LOS), Covid status (+/-), comfort care orders, and HFNC requirement. Data were analyzed for frequencies, means and percentages. Chi square (categorical) and t- tests (continuous) were performed to determine statistical significance and Pearson r (categorical) and eta (continuous) were performed to test strength of association.ResultsOf the sample (n = 91), mean age was 78 years (+/- 10.6) and mostly female (38.8%, n = 42). Mean LOS was 13.7 days (+/- 12.1). Most (71.4%) patients in the sample were Hispanic (n = 65). 63 patients had orders for comfort care (69.2%), and 61 patients were Covid positive (67%). There was a statistically significant difference in mean flow rate (p = 0.022, η = 0.564) and fi02 (p < 0.001, η = 0.688) for patients discharged to hospice vs. those who died in hospital. For patients who died in hospital, mean fi02 was 0.94 (12.2) and mean flow rate (in liters) was 48.6 (16.4). ConclusionsThe pandemic has highlighted many healthcare disparities in the United States, and made apparent the needs of persons with fibrotic lung disease at EOL. This investigation revealed that most patients in hospital opting for comfort care died in hospital as their needs for increased flow rates and fi02 far exceeds what is currently available for outpatient use of HFNC. Investments should be made into developing technologies to support these individuals with the benefits of decreased need for hospitalization and promoting self-determination at EOL.