Palliative Extubation

Palliative extubation (compassionate extubation, terminal wean) is the planned withdrawal of mechanical ventilation when the goals of care have shifted to comfort-focused measures. This is NOT euthanasia and is NOT physician-assisted death, it is the removal of a life-sustaining treatment that is no longer consistent with the patient's wishes or best interests. It is ethically and legally supported by every major medical society.

Death may occur minutes to days after extubation. Families need to understand this range. Some patients (especially those with intact respiratory drive on minimal settings) may survive for days or even be discharged to hospice.

• Patient/surrogate decision to transition to comfort care
• Terminal illness with no further curative options
• Goals of care no longer consistent with mechanical ventilation
• Advance directive specifying no prolonged mechanical ventilation

• There is no ethical or legal distinction between withholding and withdrawing treatment
• The intent is to relieve suffering, not to hasten death (principle of double effect)
• Patient autonomy: competent patients (or surrogates) have the right to refuse any medical treatment

• Family meeting: Ensure ALL key decision-makers are present (or via phone). Set clear expectations about the process and timeline. Death may occur in minutes or days.
• Discontinue monitors and alarms. The family should NOT hear alarms going off. Turn off telemetry, SpO2 monitor, ventilator alarms. Remove unnecessary lines (arterial line, etc.).
• Ensure comfort medications are at the bedside BEFORE extubation. Do not start the process until you have drawn up morphine, glycopyrrolate, and midazolam.
• Suction the oropharynx gently before extubation to minimize secretions.
• Wean ventilator settings: Reduce FiO2 to 21% and PEEP to 0 (or 5). This allows a more gradual transition rather than abrupt cessation.
• Pre-medicate: Give morphine 2-4 mg IV 10-15 minutes before extubation to prevent air hunger.
• Notify chaplain, social work if family desires.

• Remove restraints (patient should be free)
• Disconnect monitors (turn off all alarms)
• Suction oropharynx
• Reduce vent support gradually OR extubate directly (either approach is acceptable)
• Extubate: deflate cuff, remove ETT
• Apply oxygen via nasal cannula at 2-4 L (for COMFORT, not saturation monitoring)
• Assess comfort immediately, give morphine if any signs of distress
• Stay with the family (or have nursing present continuously)
• Pronounce when appropriate (no specific time requirement)

There is no diagnostic "workup" per se, but a structured checklist is essential:

• Goals of care documented?, Written consent from surrogate or documented patient wishes (advance directive).
• Ethics consult needed?, If there is disagreement among family members or between team and family.
• Legal requirements met?, State-specific requirements for withdrawal of life-sustaining treatment. Two-physician concurrence in some jurisdictions.
• DNR/DNAR order written?, Essential before extubation. Prevents Code Blue being called.
• Unnecessary interventions discontinued?, Vasopressors, antibiotics, labs, blood draws, nutrition, scheduled medications not contributing to comfort.
• Comfort medications ordered and at bedside?, Morphine, glycopyrrolate, lorazepam, haloperidol, scopolamine patch.
• Family ready and present?, Ask if they want clergy, specific family members, or rituals before proceeding.
• Organ donation discussed?, OPO should be notified per hospital protocol (may have been already).

• Comfort assessment, the ONLY vital sign that matters now. Observe for grimacing, accessory muscle use, restlessness, tachypnea as signs of distress.
• Do NOT monitor: SpO2, blood pressure, heart rate on monitors. These are turned off to avoid distressing the family with alarms and numbers.
• Secretion assessment: Listen for "death rattle" (gurgling with respirations). Treat with glycopyrrolate or scopolamine. Reassure family this is not choking or suffering.
• Medication effectiveness: After each dose, reassess in 10-15 minutes. If still distressed, redose or titrate up.
• Bedside nursing, continuous or very frequent (q15-30 min) presence. The patient and family should never be alone during this process.
• Time of death: Pronounce when breathing has ceased and no pulse is palpable. There is no specific observation period required (institutional policies vary, typically 2-5 minutes of apnea).

• Apixaban: Stop heparin → start apixaban 10 mg BID × 7 days → 5 mg BID. No overlap needed.
• Rivaroxaban: Stop heparin → start rivaroxaban 15 mg BID × 21 days → 20 mg daily. No overlap needed.
• Edoxaban: Requires 5-10 days of parenteral anticoag first → then edoxaban 60 mg daily.
• Warfarin: Start warfarin while on heparin. Continue heparin until INR 2-3 × 2 consecutive days (typically 5-7 days overlap).

• 48-72h follow-up after discharge (especially if outpatient PE treatment).
• 3-6 month reassessment: Duration decision (stop vs extend), DOAC adherence, bleeding screening.
• CTEPH screening: If persistent dyspnea at 3-6 months → echo → V/Q scan if elevated RVSP.
• Thrombophilia workup: Consider if unprovoked PE in patient < 50 (Factor V Leiden, prothrombin mutation, antiphospholipid antibodies). Test AFTER completing anticoagulation (DOACs and warfarin affect results).
• Cancer screening: If unprovoked PE in patient > 50 → age-appropriate cancer screening (colonoscopy, mammogram, CT chest, PSA if male).