Background: When transitioning patients to comfort-focused care, clinicians face an important decision about mechanical ventilator (MV) management before extubation. Practice patterns vary widely across institutions, specialties, and clinicians. Some clinicians proceed directly with extubation without adjusting MV settings, while others prefer a gradual weaning approach, administering medications to alleviate symptoms as they reduce MV support (1). This Fast Fact will compare approaches and provide recommendations for when to consider one over the other.

Definitions:  

• Palliative extubation: a common euphemism for the removal of an endotracheal (ET) tube and discontinuation of MV support with the goal of improving patient comfort and allowing natural death (1). This approach may also be called terminal or compassionate extubation (2).
• One-step extubation: a method of palliative extubation where the ET tube is removed and MV is discontinued in one-step, without any prior reduction in ventilator settings (1).
• Palliative wean: the process of reducing MV support in a gradual manner prior to palliative extubation. This process is also called a terminal wean. Weaning can occur rapidly over minutes or more slowly over hours. This allows clinicians to titrate medications for patient comfort as MV support is decreased (1-3). Most of the time, the ET tube is removed once the patient appears comfortable after the weaning process has concluded since evidence suggests that extubation prior to death is associated with increased care satisfaction for most family members (3). However, a palliative wean may be conducted without removal of the ET tube, with the intent of allowing the patient to die on little to no MV support (4-6). This approach may be selected based on family preferences or when airway concerns put the patient at risk of uncontrollable symptoms with the removal of the ET tube (e.g., large tracheal tumor) (4,7). See Fast Fact #33. Often in these circumstances, clinicians utilize a t-piece to connect the patient to room air or oxygen if they can be weaned off all MV support.

Recommended care practices regardless of MV withdrawal approach: Most patients who undergo MV withdraw at the end of life demonstrate distressing symptoms, therefore anticipatory doses of opioids and/or other comfort-focused medications is recommended no matter the MV withdrawal approach (8). Clinicians should collaborate closely with respiratory therapists and bedside nurses and utilize a validated scale such as the Respiratory Distress Observation Scale (RDOS) to guide as needed medication administration (9). It is recommended that a prescribing clinician be close on hand during the withdrawal process in case additional orders are needed. See Fast Fact #34 for more details.

Review of data: Research comparing outcomes from a one-step extubation to a palliative wean is limited to small studies with varying methodology. This makes definitive conclusions difficult.  

• Multiple studies demonstrate decreased respiratory distress symptom scores in patients that underwent palliative weaning compared to one-step extubation (2,4-6,). However, this benefit was primarily limited to patients remained on low levels of MV support (e.g., FiO2 <40%, tidal volume < 8 mL/kg, driving pressure < 15 cm H20) (10).
• One clinical trial compared one-step extubation (usual care) to a nurse-led extubation algorithm (intervention group) that used predetermined selection factors to guide whether to wean prior to extubation (5). In the intervention group, 58% required weaning prior to extubation and these patients experienced significantly lower RDOS scores and required fewer opioids and benzodiazepines.
• In pediatric populations, data is perhaps even more limited. One study of pediatric patients aged 0-21 years found that palliative weaning prior to extubation showed no significant association between time to death after extubation or with pain and sedation medication requirements (6).

Recommendations from expert panels, including the American Thoracic Society: Clinicians should use their own clinical judgment and individualize their care approach to each situation considering the existing research limitations (11-13). When the risk of respiratory distress is higher and time allows, palliative weaning may be the more comfortable approach. When loved ones prefer not to prolong the dying process, they find it very important to be at the patient’s bedside at the time of death, and/or do not wish to take the risk that the patient could die with the ET tube still present, one-step extubation may be preferred. Listed below are additional recommendations (11-13).

One-step extubation may be more appropriate for patients with:  

• Low levels of MV support (e.g., FiO2 <40%).
• Higher levels of MV support in which providers are concerned weaning may result in death prior to extubation AND there is a strong family preference for extubation before death.
• Non-responsiveness or minimal responsiveness without the use of sedatives (11-13). 

Palliative weaning prior to extubation may be more appropriate for patients with:   

• Higher MV levels AND no strong family preference that extubation must occur before death.
• Wakefulness – weaning may allow for more accurate titration of medications to optimize symptoms.
• Signs of cardiovascular shock or poor cardiac output – these patients may have increased likelihood of respiratory symptoms requiring rapid medication administration (11). 

Palliative weaning to little or no MV support (no plan for extubation) may be appropriate for patients with: 

• Tumors obstructing their airways, loss of tracheal integrity, significant tracheal edema, significant bleeding in their upper airway, or ARDS.  Patients with these conditions may be at more risk for stridor, excessive secretions, or significant respiratory distress after extubation.

References 

1. Ortega-Chen C, Van Buren N, Kwack J, et al. Palliative Extubation: A Discussion of Practices and Considerations. J Pain Symptom Manage. Aug 2023;66(2):e219-e231. doi:10.1016/j.jpainsymman.2023.03.011.
2. Mazzu MA, Campbell ML, Schwartzstein RM, et al. . Evidence Guiding Withdrawal of Mechanical Ventilation at the End of Life: A Review. J Pain Symptom Manage. Sep 2023;66(3):e399-e426. doi:10.1016/j.jpainsymman.2023.05.009.
3. Hinkle LJ, Bosslet GT, Torke AM. Factors associated with family satisfaction with end-of-life care in the ICU. Chest 2015; 147(1):82-93.
4. Robert R, Le Gouge A, Kentish-Barnes N, et al. Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study). Intensive Care Med. Dec 2017;43(12):1793-1807. doi:10.1007/s00134-017-4891-0.
5. Campbell ML, Yarandi HN. Effectiveness of an Algorithmic Approach to Ventilator Withdrawal at the End of Life: A Stepped Wedge Cluster Randomized Trial. J Palliat Med. 2024/02/01 2023;27(2):185-191. doi:10.1089/jpm.2023.0128.
6. Pringle CP, Filipp SL, Morrison WE, et al. Ventilator Weaning and Terminal Extubation: Withdrawal of Life-Sustaining Therapy in Children. Secondary Analysis of the Death One Hour After Terminal Extubation Study. Crit Care Med. Mar 1 2024;52(3):396-406. doi:10.1097/ccm.0000000000006101.
7. Thellier D, Delannoy PY, Robineau O, et al. Comparison of terminal extubation and terminal weaning as mechanical ventilation withdrawal in ICU patients. Minerva Anestesiol. Apr 2017;83(4):375-382. doi:10.23736/s0375-9393.16.11468-3.
8. Fehnel CR, Cooper Z, Campbell M.  Withdrawal of mechanical ventilation in the ICU: a prospective observational study. CHEST Critical Care 2025; 3(4):100204.
9. Ortega-Chen C, Van Buren N, Kwack J, Mariano JD, Wang SE, Raman C, Cipta A. Palliative Extubation: A Discussion of Practices and Considerations. J Pain Symptom Manage. 2023 Aug;66(2):e219-e231. doi:10.1016/j.jpainsymman.2023.03.011.
10. Goodfellow LT, Miller AG, Varekojis SM, et al. AARC Clinical Practice Guideline: Patient-Ventilator Assessment. Respir Care. Jul 24 2024;69(8):1042-1054. doi: 10.4187/respcare.12007.
11. Paruk F, Kissoon N, Hartog CS, et al. The Durban World Congress Ethics Round Table Conference Report: III. Withdrawing Mechanical ventilation–the approach should be individualized. J Crit Care. Dec 2014;29(6):902-7. doi:10.1016/j.jcrc.2014.05.022.
12. Lanken PN, Terry PB, Delisser HM, et al. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med. Apr 15 2008;177(8):912-27. doi:10.1164/rccm.200605-587ST.
13. Truog RD, Cist AF, Brackett SE, et al. Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med. Dec 2001;29(12):2332-48. doi:10.1097/00003246-200112000-00017  

Authors’ Affiliations:  1 University of Texas Southwestern Medical Center Dallas; Texas.
                                               2 Louisiana State University Health Science Center New Orleans, Louisiana.
Conflicts of Interest:  The authors have no conflicts of interest to disclose.
Version History: First electronically published in February 2026; originally edited by Sean Marks MD.