Clinical Voices April 2026

End-of-Life Guidelines Emphasize Unified Care

New guidelines for adult EOL care in the ICU include the need for standardized processes.

New guidelines for end of life (EOL) care in the ICU call for clearer communication with families, stronger support for decision making and coordinated teamwork across disciplines to align treatments with what patients can realistically achieve and reduce suffering.

“Society of Critical Care Medicine Clinical Practice Guidelines on Adult End-of-Life Care in the ICU ,” in Critical Care Medicine, highlights the need for standardized processes, including identifying legal surrogates, using shared decision making tools and adopting protocolized withdrawal pathways.

Additional priorities include early palliative care involvement, spiritual support and focused education to reduce conflict. Recommendations are summarized in three major areas:

• Communication – Use structured tools to support shared decision-making and provide resources that help substitute decision-makers understand their roles. Ensure every patient has a clearly identified legal surrogate. Early involvement of palliative care or ethics services is encouraged when treatment goals are unclear or conflict arises.
• Symptom management – Follow protocolized approaches to withdrawing life sustaining treatments, including assessing and treating symptoms before, during and after extubation. Clinicians are urged to recognize and support cultural, spiritual and family traditions that may shape how patients and families experience EOL care.
• Education – ICU teams should receive palliative care training to strengthen EOL support. Clinicians are encouraged to educate patients, families and surrogates at risk of ICU admission about treatment options and advance-care planning, with attention to gender, identity, race, culture, language and socioeconomic context.

A related article in PulmCCM calls on hospitals to support ICU teams by taking responsibility for the demanding nonclinical work of bedside clinicians. One suggestion involves hiring RN‑trained “ICU navigators” to regularly communicate with families facing EOL decisions, lead family meetings and provide education using prebuilt resources.

“Without saying so, the guidelines challenge hospital systems, who regularly profess their concern for clinician burnout, to begin to put their resources where their PR is,” the article adds.

New Guidelines on Managing Difficult Airways

The first update since 2015, the guidelines focus on successful first attempts.

Updated guidelines on difficult airway management focus on maximizing the possibility of success rather than avoiding or managing failure, with strategies that start with assessment and include preparation for several courses of action.

“Difficult Airway Society 2025 Guidelines for Management of Unanticipated Difficult Tracheal Intubation in Adults,” in British Journal of Anaesthesia, is the first update since 2015 and focuses on successful first attempts and being ready for plans A through D from the beginning. “Importantly, we advocate for early recognition that an attempt at any technique is unsuccessful, learning from this failure for subsequent attempts, and promptly moving on to the next step of the algorithm,” the guidelines add.

Best practices begin with an airway assessment strategy that includes “any anticipated difficulty in facemask ventilation, SAD [supraglottic airway device] insertion or ventilation, tracheal intubation, eFONA [emergency front-of-neck airway] and physiological status.” The guidelines offer several recommendations for patient monitoring, selection of appropriate anesthesia and pre-oxygenation:

• Plan A, tracheal intubation, follows a guideline of 3+1 attempts, with a more experienced clinician performing the fourth attempt, if necessary, and at least one change of conditions accompanying each successive attempt.
• Plan B, SAD, should be used for a maximum of three attempts instead of facemask ventilation as the secondary option.
• Plan C would be a final attempt at facemask ventilation, which is among the tools available at each step but can frequently create difficulties.
• Plan D is eFONA surgery.

“Consideration should also be given to patient positioning, equipment, personnel, location, timing, plans for failure of any of the proposed techniques, and communication with the wider team.”

The results of multiple studies could help refine some of the recommendations in the near future, the guidelines add. Artificial intelligence tools and improved devices also could transform clinical practice and play key roles in airway management.

The winter 2025 issue of AACN Advanced Critical Care offers ”Symposium: Advanced Pulmonary Care,” including an article on airway management and a CE article on mechanical ventilation.

Drones Fly AEDs to Cut Response Times

Drones can lower response times from an average of six or seven minutes to less than four.

A Duke Health study is testing whether drones carrying automated external defibrillators (AEDs) can lower response times and potentially improve cardiac arrest survival rates by delivering the devices sooner than EMS, who are dispatched at the same time.

Launched in partnership with the Forsyth County Sheriff’s Office in Clemmons, North Carolina, the first-of-its-kind project dispatches drones to the locations of 911 calls, thus avoiding indirect routes and traffic delays, notes “In a U.S. First, Drones Deliver AEDs in North Carolina County,” in Duke Today. When the drone lands, 911 operators help bystanders use AEDs.

“We have done research to strategically position drones to lower response times from an average of six or seven minutes to under four minutes,” says lead study author Monique Starks, a Duke Health cardiologist. “And that is very important, particularly in rural areas where response times can be 12 minutes.”

Survival rates could reach 50%-70% if patients are shocked within two to five minutes, but Starks notes that current rates are 10%, largely because AEDs don’t arrive until EMS does. With most cardiac arrests occurring in homes, only 1%-4% involve someone using an AED.

“We want to get that AED to the bystander, so that they can rapidly shock a cardiac arrest patient to help them survive,” Starks adds in the article.

Forsyth County Sheriff Bobby Kimbrough emphasizes that drones are meant to supplement EMS rather than replace it: “It’s just that we’re coming by air, and they’re coming by ground.”

A related article in Cardiovascular Business notes the project is supported by the American Heart Association and many universities. “This project is laying the groundwork for what we hope will become a large, multicenter randomized clinical trial,” notes co-principal investigator Joseph Ornato, Virginia Commonwealth University. He adds that future studies will help answer essential questions, including program costs and how quickly AEDs can reach both rural and urban settings.

Cardiac Nurses’ Perspectives on Palliative Care Planning

The analysis, which involved interviews with cardiac nurses, identified three key themes.

Cardiac nurses indicate that palliative care for patients with heart failure (HF) is often confusing and difficult to navigate, with unclear roles, mixed expectations and little guidance on when or how to begin end-of-life conversations.

“Navigating Uncertainty and Vulnerability: Cardiac Nurses’ Perspectives on Providing Palliative Care for Patients With Late-Stage Heart Failure,” in Heart & Lung: The Journal of Cardiopulmonary and Acute Care, finds that lack of a shared plan between nurses and cardiologists can contribute to nurses’ uncertainty and lead to missed opportunities to honor patients’ preferences.

The analysis involved interviews with 18 nurses from cardiac wards and HF clinics at two university hospitals in Denmark. The nurses emphasized that caring for patients with advanced HF requires more unified, interdisciplinary collaboration than they currently experience.

The analysis identified three key themes: determining the appropriate level of treatment, finding space for palliative care while honoring patients’ wishes, and strengthening organizational support.

“We need to be present in their illness with and for them,” one nurse said in an interview. “How do you find room for this conversation? It can be stressful and make you hectic. So, you are not calm, and calmness is a precondition for being in the room with the patient.”

Another nurse described occasions when the team felt they did “not know what to do” during complex patient trajectories.

“I dream about interdisciplinary cooperation in which nurses and cardiologists discuss treatment and care, and include the palliative team in the discussions, as well as the physiotherapist,” the nurse added. “We do it, but not systematically. The palliative team can mentor and guide us.”

The analysis notes that future research can help identify the barriers, facilitators and clinical perspectives that shape early palliative care integration for patients with HF. In addition, educational efforts should focus on implementing models that enhance interdisciplinary teamwork and patient involvement.

“Innovative Strategies for Palliative Care in the Intensive Care Unit,” in AACN Advanced Critical Care, describes two innovative approaches that support identifying patients who could benefit from goals-of-care conversations. AACN also offers a Palliative Care in Acute & Critical Care Settings Clinical Resource.

AASM Releases First Guideline for Patients With Obstructive Sleep Apnea

The treating clinician and the patient must make the ultimate decision for specific care.

The first guideline for adult patients with obstructive sleep apnea (OSA) from an expert task force commissioned by the American Academy of Sleep Medicine provides a good practice statement and four conditional recommendations.

In “Evaluation and Management of Obstructive Sleep Apnea in Adults Hospitalized for Medical Care: an American Academy of Sleep Medicine [AASM] Clinical Practice Guideline,” in JCSM: Journal of Clinical Sleep Medicine, the task force did not reach any strong recommendations because of the low certainty of evidence: “The recommendations provided are intended to serve as a guide to move the field forward in prioritizing the need to develop systematic approaches to manage OSA in the inpatient setting as the nascent field of inpatient sleep medicine continues to evolve.” A news release about the guideline is also available.

The good practice statement is a necessity for effective patient treatment, the guideline adds: “For medically hospitalized adults with an established diagnosis of sleep-disordered breathing and on active treatment, existing treatment should be continued rather than withheld, unless contraindicated.” The guideline suggests using a patient’s own positive airway pressure device and mask, if possible, for comfort and potential cost savings.

The four conditional recommendations are not necessarily applicable to all patients: “The ultimate judgment regarding any specific care must be made by the treating clinician and the patient, taking into consideration the individual circumstances of the patient, available treatment options and resources.”

The guideline adds that randomized clinical trials and observational studies could supply stronger evidence for screening approaches, diagnostics and interventions for both OSA and central sleep apnea (CSA). “Clinical trials (with high consideration of pragmatic clinical trials) to assess the effect of screening and management of OSA including understudied areas of CSA and sleep-related hypoventilation are needed with a focus on clinical outcomes, patient reported outcomes and cost-effectiveness to optimally inform clinical management pathways.”

ECRI Report Highlights Top Technology Hazards for 2026

Misuse of AI chatbots is listed as the top hazard.

An annual report detailing the top health technology hazards for 2026 identifies misuse of artificial intelligence (AI) chatbots as the biggest threat, along with several others involved in critical care nursing.

“Top 10 Health Technology Hazards for 2026 Executive Brief,” a white paper from ECRI, assesses general emerging topics as well as recurring ones that pose the biggest risks to patient safety. “This year’s report emphasizes the growing necessity for healthcare organizations to strengthen and enhance their technology selection, implementation and monitoring processes,” the report notes.

Following misuse of AI chatbots, the second hazard on the list is organizations’ unpreparedness for digital darkness events, which is a loss of access to patient information and systems potentially caused by a cyberattack, natural disaster, or a system outage or failure. ECRI advises strengthening disaster preparedness and recovery planning, including exercises and training to manage recovery in a live patient environment.

Ranking fifth for 2026 is misconnected tubing due to slow adoption of ENFit (enteral feeding) and NRFit (neural axial applications such as epidural) connector products that are better designed for safety. The report cites the risks involved in using connectors intended for different uses, including patients receiving incorrect medications, feeding or solutions via the wrong line.

In the eighth spot on the list are cybersecurity risks created by legacy medical devices that are more susceptible to hacking due to software and systems that are no longer updated with proper protections. Organizations can disconnect such devices and systems from their networks, upgrade to safer technology or enhance security tools, the report adds.

Ranking ninth on the list are technologies implemented without careful regard for the workflows of frontline staff, where designs and configurations could lead to patient harm due to misunderstanding clinical practice. ECRI recommends that multidisciplinary teams with clinical knowledge work collaboratively on new technology selections and configurations, including workflow analysis and comprehensive training.

Community Advocacy: “Something Bigger Than My Job”

For Aron King, a community-engaged nurse leader, nursing is a profession and a platform. In this video conversation, King discusses his path from associate-degree-prepared nurse to Magnet^® program director at a Northern California hospital. He shares how purpose and community engagement continue to guide his work and why varied pathways into nursing are essential for the profession.

Meet Aron King