ABSTRACT
In patients with acute respiratory failure who have decided to forego intubation and mechanical ventilation after consideration of the risks/benefits and expected outcomes of therapy, NIV may be a therapeutic option if it is in keeping with the established goals of care. Prior to initiation of NIV, it is critical that the patient, family and clinicians have a clear understanding of the possible outcomes of NIV. Their discussion should include the wishes of the patient for survival, as well as possible time limits of NIV. Potential use of NIV, including the risks, benefits and alternatives, should be incorporated into discussions of other life-sustaining treatments. The intended effect of NIV in this situation should be to restore the patient to their previous state of health (if so desired by the patient) or to prolong life for a sufficient period of time to accomplish a predefined goal (i.e. arrival of a family member). It should also provide comfort through the relief of dyspnoea. Frequent reassessment of the success or failure of NIV, including patient tolerance, should be performed. If NIV fails to accomplish the previously defined goals or the patient cannot tolerate NIV, these aspects of care should be reviewed with the patient or family and careful consideration should be given to changing the goals of care and withdrawing NIV.
