Décisions de non admission et de limitation thérapeutique chez l'insuffisant respiratoire chronique en réanimation

Chronic respiratory failure (CRF) is one of the most common underlying illnesses in ICU patients in whom death is preceded by a decision of withdraw or withhold life support. The number of CRF patients is growing because the prevalence of chronic obstructive pulmonary disease (COPD), a major cause of chronic morbidity and mortality, is increasing. The following medical situations could lead to a decision of not admitting to the ICU: end-stage idiopathic pulmonary fibrosis (IPF) or cystic fibrosis (CF) in patients not included in a lung transplant program, amyotrophic lateral sclerosis (ALS) treated by home noninvasive ventilation in patients who did not want long term ventilation by tracheostomy, any form of CRF associated to another illness with poor short-term prognosis. In ICU, the reasons leading to a decision-making process of life support treatment withholding or withdrawing could be the futility of care (advanced IPF or CF patients receiving prolonged invasive mechanical ventilation without identified reversible cause of respiratory failure) or the future poor quality of life (ventilator-dependent patients with ALS or severe COPD who are not candidate for home ventilation by tracheostomy). The patients must be involved in the decision-making process as they are judged to be competent. In patients with end-stage lung disease, it is important to stimulate discussion about advance care planning before the onset of acute respiratory failure and a possible admission to the ICU.