August 2025
| Consult institutional protocol and individualize as necessary |
| Preparatory steps |
| Reach consensus at family/caregiver/surrogate meeting regarding discontinuation of mechanical ventilation for palliation purposes*. |
| Prepare family/caregiver/surrogate for the steps involved and anticipated changes in respiratory pattern, encourage them to gather close family/caregivers/friends and visit the patient, and provide ancillary staff for support (eg, palliative team member, social worker, chaplain). |
| Select a suitable time with the family/caregiver for terminal weaning/extubation. |
| Discontinue NMBs in accordance with their half-life; consider nerve stimulation to ensure no active NMB is on board. |
| Ensure a documented DNR/I order is in place. |
| Ensure intravenous access is secured. |
| Prepare equipment for suctioning. |
| Ensure that intravenous analgesics and sedatives are at the bedside (eg, morphine 1 to 10 mg, fentanyl 100 to 400 mcg, midazolam 1 to 5 mg); anticipate what infusions may be needed. |
| Remove any unnecessary equipment (eg, soft ties, mitts). |
Excessive airway secretions¶
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| Provide a quiet space for family to gather and sit. Consider a "comfort cart" with refreshments. |
| Procedure |
| Families/caregivers/surrogates are asked to spend time with their loved one and signal to the team when they are ready. |
Perform gradual wean (our preferred approach).Δ Ventilator is decrementally weaned every 10 to 15 minutes to zero support.◊ Respiratory distress or other symptoms are assessed and treated with intravenous bolus medications (eg, opioids and/or benzodiazepines) before proceeding with the next weaning step.§ Our approach is the following:
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| Rapid titration of opioid analgesics may be required to alleviate any unexpected respiratory distress immediately after extubation (eg, unknown upper airway obstruction). |
| Remove ventilator from the room. |
| Postextubation |
| Document the procedure. |
| Discontinue measures that are unnecessary after extubation (eg, blood draws, radiographs, oxygen, medicines, routine vital signs, dialysis, nutrition, intravenous hydration‡). |
| Continue to treat symptoms of discomfort; continuous infusions may be necessary†. |
| Update family and inform of transfer to hospital bed if stable after 24 hours. |
| Bereavement support (eg, spiritual counseling, soft music, observing silence, or information packets). |
DNR/I: do-not-resuscitate/intubate; FiO2: fraction of inspired oxygen; NMB: neuromuscular blockade; PEEP: positive end-expiratory pressure.
* Involving palliative care consultants during family/caregiver meetings as well as after extubation is appropriate in many cases.
¶ Anticholinergic (antimuscarinic) therapy may not prevent "rattling" that can occur after extubation in the dying patient. Anticholinergic effects may contribute to patient discomfort (eg, dryness, urinary retention) and do not dry secretions already present. Glycopyrrolate, a quaternary amine, is less likely to cause central nervous system adverse effects (agitation, delirium) than scopolamine patch. Scopolamine is also known as "hyoscine" in many countries.
Δ Immediate extubation is an alternative and may be suitable for patients with severe neurologic injury and minimal sedation needs. This involves a single step of turning off the ventilator and extubating the patient, without any preceding reductions in the ventilatory support or oxygen delivery. It is ensured that the patient is comfortable on ventilatory settings. Anticipatory doses of sedatives are often given before extubation. The endotracheal tube is removed in the standard fashion and any postexubation distress treated.
◊ Some clinicians "pre-wean" to see if the patient tolerates lower levels of pressure support.
§ Clinician judgment is involved with respect to dosing and may depend upon previous dosing of continuous infusion of opioids and benzodiazepines.
¥ Family/caregivers may be asked to stay or leave the room for a few minutes during the extubation procedure. If they request to stay, they should be informed of what to expect. The extubation procedure is similar to that in patients undergoing nonpalliative extubation, except the patient is not instructed to breathe after endotracheal tube removal and oxygen is not applied. Refer to UpToDate content on extubation in the intensive care unit. Rarely, the endotracheal tube is left in place (eg, known upper airway obstruction).
‡ Some clinicians attempt to remove as much fluid in advance for comfort measures. Vasopressors are often not discontinued until after extubation to ensure adequate circulation of medications during weaning and extubation. Turning off a pacemaker may be discussed with the patient/family/caregiver/surrogate.
† There is no uniformly ideal starting dose for infusions. If infusions are newly initiated, we typically start at one-half of the bolus dose required to alleviate symptoms (eg, if morphine 12 mg alleviated symptoms, the infusion can be initiated at 6 mg/hour and titrated up or down as needed).
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