Invasive mechanical ventilation: Concerns over terminal extubation

Janete Maria da Silva, MSc, a physiotherapist, and Dr Ricardo Tavares de Carvalho, Coordinator of Palliative Care, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo and Director of the Instituto Paliar, São Paulo, Brazil, explain the background to their longer article published in the current issue of the European Journal of Palliative Care.

Dr Ricardo Tavares de Carvalho

Janete Maria da Silva

Invasive mechanical ventilation (IMV) is a technological and therapeutic resource used in the treatment of respiratory failure. Most palliative care patients with several clinical conditions will develop respiratory failure at the end of life. However, the use of IMV with these patients leads to an important discussion. Is it the best practice?

Dying intubated, in an intensive care unit and undergoing IMV, are poor quality-of-care indicators at the end of life for patients with cancer. 1

So why do we intubate and submit patients to IMV? Basically, because of the following reasons:

  • Difficulty in identifying the last hospitalisation, particularly in the case of patients with chronic pulmonary diseases and cardiac failure (which presents many moments of decompensation and clinical improvement after intensive treatment until the death). Patients with organic failure such as pulmonary and cardiac chronic diseases commonly present several episodes of acute decompensation during the course of disease progression. To a limited extent, these patients are responsive to the intensive treatment that may be offered in the intensive care unit. This happens to be a confusing factor, because, knowing that the patient can have several episodes of decompensation during the progress of the disease, how will we know that is it the last hospitalisation? (In figure 1 below, the graph explains the multiple episodes of decompensation with the improvement of functional status after intensive treatment until death). 2
  • Lack of time to discuss, or implement, advance care planning;
  • Lack of resources to develop a good communication with patient, family and allied health professionals;
  • The documented wish of the patient and their family.

Figure 1: 
Thus, our palliative care patients are at risk of undergoing intubation and IMV during the course of the disease. Once implemented, the IMV is one of the most difficult therapeutic resources to be withdrawn. The withdrawal of IMV when the patient is actively dying is defined as terminal extubation. In fact, the decision-making process related to the terminal extubation is difficult and is directly linked to moral, ethical and cultural aspects of dying around the world.

In clinical practice, we have observed that health professionals find it more acceptable to withdraw vasopressors drugs and renal replacement therapy than IMV. Many professionals feel uncomfortable to talk about terminal extubation with patients and their families. However, it is an essential conversation.  In addition, it should be good practice to involve multidisciplinary team members throughout the process. Why? Because terminal extubation requires adequate planning and protocols to assure quality control, mainly after the procedure, when the management of symptom control depends on an integrated multidisciplinary team using pharmacological and non-pharmacological approaches. There are still many steps to go to make terminal extubation an ethical and good practice. If you are interested in reading more about terminal extubation, we invite you to read our article, ‘Invasive mechanical ventilation: Concerns over terminal extubation’, published in the European Journal of Palliative Care, and you can also contact us at the links below.

References and Links

1.Tang ST, Wu SC, Hung YN et al. Trends in quality of end-of-life care for Taiwanese cancer patients who died in 2000–2006. Ann Oncol 2009;20:343–348.

  1. In: Murray AS et al. BMJ 2003; 330:1007-11.

Contact the authors by email

Read the full article in the European Journal of Palliative Care
This post relates to a longer article, ‘Invasive mechanical ventilation: Concerns over terminal extubation’, published in the May/June 2017 edition of the European Journal of Palliative Care (EJPC). (vol. 24.3).

If you have a web-based subscription to the journal you’ll be able to download this issue, plus all articles in the journal archive. You can also browse the archive and download articles by taking a 10-minute or 30-minute subscription. Members of the EAPC receive discounted subscription rates to the journalclick here to subscribe online.

Read more posts relating to articles published in the European Journal of Palliative Care on the EAPC Blog.

This entry was posted in EAPC-LINKED JOURNALS, European Journal of Palliative Care, Therapies and tagged , . Bookmark the permalink.

1 Response to Invasive mechanical ventilation: Concerns over terminal extubation

  1. Mary Tehan says:

    I can imagine the angst in this conversation but I have found that, whenever there is an ongoing invasive procedure undertaken, it is helpful to ALWAYS engage in a conversation that includes a formal review date on a regular basis … it can become a form of preparation to face a final conversation and outcome (withdrawal) that is embedded in trust, respect, humility and good intent … fundamental to a sense of completion that brings peace of mind.

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