Abstract
Terminal extubation, the planned withdrawal of mechanical ventilation from patients who will not recover, presents significant technical, ethical, and emotional challenges for respiratory therapists (RTs), yet their perspectives remain underexamined. Using Max Weber’s concept of ideal types, this interpretive description study explored how RTs understand and enact their role at life’s end. Twenty-nine RTs (20 in Canada and 9 in the United States) participated in semi-structured video interviews. Analysis revealed a continuum between two orientations: task-centered RTs emphasize technical precision, protocol adherence, and emotional detachment, often relying on informal or maladaptive coping strategies. Event-centered RTs approach extubation as a shared human experience, integrating emotional presence with clinical skill and supporting families and teams, though institutional support for such practices is limited. These orientations are fluid and context-dependent. Findings extend Weberian theory by showing how instrumental, value-rational, affective, and traditional motives converge in a single clinical act. To better support RTs, we recommend (a) inclusion in decision-making and debriefing, (b) training that blends technical and relational competencies, and (c) policies that legitimize diverse ways of “doing” terminal extubation. These shifts could reduce burnout, foster collaboration, and improve end-of-life care for patients and families.
Introduction
Terminal extubation, the deliberate withdrawal of mechanical ventilation from critically ill patients who are not expected to recover, remains one of the most ethically intricate and emotionally charged procedures in contemporary critical care (Rocker, 2006; Winter & Cohen, 1999). Because the intervention directly precipitates death, clinicians must balance high-stakes technical competence with profound moral responsibility and human emotion (Blythe et al., 2022).
Terminal extubation typically occurs after a family meeting in which the decision to withdraw life-sustaining treatment has been made. The composition of these meetings varies considerably across institutions: in some settings, the conversation involves only the physician and family, while in others it includes nurses, social workers, respiratory therapists (RTs), and other members of the interprofessional team. Prior to extubation, patients are generally deeply sedated and receive comfort-focused medications, such as opioids and anxiolytics, to minimize distress. Families may be invited to be present during the procedure itself, though this too varies by institutional culture and family preference. Nurses play a central role throughout this process, coordinating comfort care and providing emotional support to families, yet the RT performs the physical act of removing the endotracheal tube, a role that is technically and emotionally distinct.
Although the experiences of physicians, nurses, and family at the end of life have been well documented (Bruce et al., 2015; Choi et al., 2023; Heradstveit et al., 2023), the perspectives of RTs, the clinicians who physically remove the endotracheal tube, remain comparatively under-explored (Cullum et al., 2022; Orr et al., 2022). Positioned within the interprofessional critical care teams, where, despite widespread norms of collaborative decision-making, formal authority over withdrawal decisions typically rests with physicians, RTs shoulder the technical act that ends ventilatory support while often having limited formal input into whether, when, or how withdrawal occurs, though the extent of RT involvement varies considerably across institutions and practice contexts (Chartrand, 2018; Cottereau et al., 2016). This unique role can heighten tension between their professional identity as life-sustaining caregivers and their momentary function as agents of life’s conclusion.
Beyond technical execution, terminal extubation is saturated with ethical, emotional, and relational complexities. Clinicians must manage their own affect, support distressed families, and collaborate within hierarchical interprofessional teams. Emerging data suggest saf that RTs experience pronounced moral distress and a sense of powerlessness during end-of-life decision-making (Houston et al., 2013; Piquette et al., 2023), yet they are expected to maintain composure while performing actions that may jar with personal values (Cullum et al., 2022).
Modern healthcare policy champions patient-centered care and interprofessional collaboration (American Association of Critical Care Nurses, 2005; McLaney et al., 2022). In practice, however, RTs are often excluded from key family meetings and treatment conferences despite their integral role in ventilator withdrawal (Blythe et al., 2022; Cottereau et al., 2016). This gap between institutional ideals and day-to-day realities amplifies occupational stress, though the degree of RT agency is not uniform: as our own findings illustrate, practitioners in rural or community settings may have considerably greater involvement in decisions and family conversations. The tension between espoused collaborative values and enacted authority is therefore best understood as context-dependent rather than categorical.
The emotional labor inherent in terminal extubation, a concept first theorized by sociologist Hochschild (1983), referring to the work of managing one’s feelings to fulfil the emotional requirements of a job constitutes a significant psychological load for RTs (Brighton et al., 2019; Moscoso et al., 2012). Yet, how RTs navigate this terrain, what coping strategies they deploy, and how these strategies shape their overall experience remain poorly characterized. Clarifying these dynamics is essential for designing effective supports and safeguarding both clinician well-being and care quality (Moss et al., 2016).
To address these gaps, the present study makes an original contribution by providing the first in-depth examination of how RTs perceive and enact their role during terminal extubation through a Weberian ideal-type framework. In doing so, it extends both the sociology of healthcare work and the clinical literature on end-of-life care by revealing how a single procedure can be experienced and performed in fundamentally different ways, with direct implications for RT well-being, interprofessional collaboration, and the quality of care at life’s end. Drawing on Max Weber's concept of ideal types as an analytic constructs for interpreting the orientations and meanings that shape social action, we explore the meanings RTs attach to their practice (Aronovitch, 2012; Swedberg, 2018; Weber, 2011).
Theoretical Framework: Max Weber’s Ideal Types
Max Weber’s concept of the ideal type is a cornerstone of interpretive sociology, offering a methodological tool to clarify and analyze the internal logic of social action. Unlike empirical categories or psychological typologies, ideal types are abstract, analytical constructs that accentuate certain features of a phenomenon to facilitate understanding and comparison. Weber described the ideal type as a “one-sided accentuation of one or more points of view,” synthesizing a range of concrete phenomena into a unified analytical model (Swedberg, 2018; Weber et al., 1949). Importantly, these constructs do not correspond to reality in its entirety; rather, they serve as reference points or “measuring rods” against which real-world cases can be compared (Eliaeson, 2000).
The value of ideal types lies in their ability to make sense of complex phenomena by highlighting essential characteristics, thereby enabling comparative analysis and interpretive understanding (Verstehen) (Aronovitch, 2012; Delaney, 2024; Weber et al., 1949). For example, Weber’s ideal type of bureaucracy does not exist in pure form but provides a standard for analyzing how actual organizations diverge from or approximate the model (Swedberg, 2018; Weber, 2011; Weber et al., 1949).
It is important to emphasize, considering the potential misreading of ideal-type analysis as imposing rigid categorical boundaries, that Weber designed these constructs explicitly as heuristic devices rather than descriptions of empirical reality (Eliaeson, 2000; Swedberg, 2018). In the present study, the task-centered and event-centered ideal types do not represent discrete or mutually exclusive categories. Rather, they anchor opposite ends of a fluid continuum; any given practitioner may occupy different positions depending on patient, family, team, and institutional context. This interpretive flexibility is intrinsic to the Weberian approach. The framework was chosen precisely because it accommodates nuance: it allows us to name and examine tendencies without implying that individuals are fixed or uniform in their orientations.
Weber’s typology of social action offers a foundational framework for understanding how individuals act meaningfully within social contexts, particularly in complex institutional environments like healthcare. He identified four ideal types of action, each reflecting a distinct mode of motivation: instrumental-rational (Zweckrational) action oriented toward achieving specific goals through calculated means; value-rational (Wertrational) action guided by commitment to intrinsic values or ethical principles; affectual action stemming from emotional states; and traditional action based on ingrained habits or customs (Aronovitch, 2012; Hanemaayer, 2021; Weber et al., 1949).
Application to Healthcare Contexts
In healthcare settings, professionals often navigate multiple action orientations simultaneously. Terminal extubation represents a particularly complex scenario where institutional protocols (instrumental-rational), professional ethics (value-rational), emotional responses (affectual), and established practices (traditional) intersect. While the procedure may be formally structured as instrumental-rational action, a technical task ordered by physicians and executed by RTs, the subjective experience of those performing it can incorporate elements from all four action types.
This theoretical lens is particularly valuable for understanding RTs’ experiences during terminal extubation. RTs occupy a unique position in this process: they are typically excluded from decision-making conversations between physicians and families, yet they perform the physical act that ends ventilatory support (Goodridge & Peters, 2019; Grandhige et al., 2016). This positioning, which, as our data illustrate, is not uniform across all practice contexts, can create tensions between their formal role as technical executors and their personal responses to participating in life-ending procedures. Institutional context, including hospital size and culture, may shape the degree of RT involvement in decision-making: a pattern that emerged in our data and that invites further study.
Methodology
Philosophical Approach and Study Design
This study employed an interpretive description methodology, selected for its applicability to health and social science research that seeks to generate meaningful, practice-relevant insights while interpreting participants’ experiential knowledge (Thorne et al., 1997; Thorne & Ebooks, 2016). Interpretive description is grounded in a constructivist epistemology that recognizes knowledge as socially constructed through human experience and interaction (Thorne, 2025). This approach was particularly suited to exploring the complex, subjective experiences of RTs during terminal extubation, as it allows for the examination of both individual meaning-making processes and broader social patterns.
Study Setting and Context
Data were collected from RTs working in intensive care units (ICUs) across Canada and the United States, including urban and rural hospitals, academic medical centers, and community hospitals. This diversity in practice settings was intentionally sought to capture a range of institutional cultures and patient populations that might influence RTs’ experiences of terminal extubation. Ethics approval was obtained through the Health Research Ethics Board of the University of Manitoba (HS22819 [H2019:181]).
Participants and Recruitment
A total of 29 RTs participated in this study, including 20 from Canada and 9 from the United States. Participants ranged in experience from 3 to 35 years of practice (mean: 15 years), with representation from various types of healthcare institutions including academic medical centers, community hospitals, and rural facilities. Most worked in adult ICUs; a smaller number had pediatric or neonatal experience, always alongside adult or pediatric critical care. Inclusion criteria were licensed RTs with at least two years of critical care experience, direct experience with terminal extubation procedures, currently practicing or recently retired (within 2 years), and ability to participate in English or French language interviews. Exclusion criterion was RTs working exclusively in non-critical care settings.
Participants were recruited through purposive and snowball sampling strategies, facilitated through professional and social networks. Specifically, recruitment was conducted via posts in a large RT Facebook group (Respiratory Break Room, with approximately 25,000 members) and through email blasts distributed by national respiratory therapy organizations in both Canada (Canadian Society of Respiratory Therapists) and the United States (American Association for Respiratory Care). The Facebook group post described the study purpose and included contact information for interested participants. Professional organizations distributed recruitment emails to their membership lists.
Initial participants were recruited through these formal channels, and subsequent participants were identified through snowball sampling, where interviewed participants referred colleagues who met the inclusion criteria. This combined approach helped ensure diversity in experience, geographical location, and practice settings while accessing participants who might not be reached through formal professional channels alone.
Data Collection Procedures
All interviews were conducted virtually in 2019 using secure, HIPAA-compliant video-conferencing platforms (Zoom Pro). Virtual interviews were chosen to enable participation across wide geographical areas and to accommodate participants’ scheduling constraints. Interviews lasted between 45 and 90 min (mean duration: 67 min). The video modality was used exclusively to enable face-to-face rapport and to allow interviewers to monitor participants’ visual cues, such as facial expressions and body language, in real time, as part of the distress protocol. Video was not recorded or analyzed as a separate data source; analysis was based solely on the verbatim audio transcripts.
Three qualitative researchers conducted the interviews: LC, DK, and LS. To ensure consistency and coherence across interviews, DK and LS followed training from LC. This training addressed two interconnected dimensions. The first was methodological: maintaining continuity in structure, tone, and focus across interviews while allowing flexible exploration of emerging themes. Consistency across interviewers was further supported through pilot interviews conducted prior to data collection, regular debrief meetings held throughout the data collection period, and the Principal Investigator (PI)’s independent review of early transcripts. The second concerned the ethical and emotional demands of conducting sensitive research; mainly, the participants distressed protocol to make sure interviewers were safe (Dickson-Swift et al., 2007; Liamputtong, 2007).
A semi-structured interview guide was developed based on existing literature on end-of-life care, professional identity, and preliminary discussions with RTs. The guide included broad, open-ended questions designed to elicit rich descriptions of participants’ experiences, such as: “Can you describe a recent experience you had with terminal extubation?”, “How do you understand your role as a respiratory therapist in these situations?”, “How do you interact with families during these procedures?”, and “How do you cope with these experiences?”
The interview guide was refined iteratively based on insights from early interviews, with probing questions added to explore emerging themes more deeply. Interviews explored RTs’ experiences of terminal extubation; their perceptions of their professional role in this context; their interactions with patients, families, and healthcare teams; and their reflections on the ethical, emotional, and relational dimensions of their work.
Data collection began in March 2019 and was temporarily paused in March 2020 at the onset of the COVID-19 pandemic. Although additional interviews were later conducted to explore RTs’ experiences during the pandemic, these data are not included in the present analysis, which focuses exclusively on the 29 pre-pandemic interviews to maintain consistency in the healthcare context being studied.
Researcher Reflexivity and Positionality
Consistent with the epistemological commitments of interpretive description (Thorne & Ebooks, 2016) and with best practice in sensitive qualitative research (Dickson-Swift et al., 2007), the research team engaged in ongoing and formal reflexivity throughout data collection and analysis. This reflexivity addressed three interconnected dimensions. First, researchers reflected on their own personal relationships to death and dying including prior experiences of loss and the ways in which these shaped their emotional responses as listeners and their interpretive instincts as analysts. Second, following interviews that were particularly emotionally demanding, the team met to discuss their reactions, to process the affective dimensions of the work, and to ensure that emotional responses to specific participants or accounts were named and examined rather than left to operate silently on the analysis. Third, researchers reflected explicitly on how their own views about end-of-life care, professional roles, and the ethics of ventilator withdrawal might incline them toward interpretations of the data. These reflexive practices were documented through written memos maintained by each interviewer and through regular team debriefing meetings held throughout the data collection period (Dickson-Swift et al., 2007).
Data Management and Preparation
All interviews were audio-recorded with participants’ consent and transcribed verbatim by a professional transcription service. Transcripts were reviewed for accuracy by the research team, with particular attention to technical terminology and emotional nuances in participants’ speech. Participants were assigned pseudonyms, and all identifying information was removed from transcripts. Interview transcript was stored securely using encrypted, password-protected files accessible only to the research team.
Analytical Approach
Interviews were analyzed using interpretive description strategies (Thorne & Ebooks, 2016). The analytical process began with multiple readings of each transcript to develop familiarity with the data. Initial coding was conducted inductively by two researchers LC and SL working independently, generating codes that represented key characteristics of how RTs described their actions, interactions with families, coping mechanisms, and overall experiences during terminal extubation.
The research team met regularly to discuss emerging codes, compare interpretations, and resolve discrepancies through discussion and consensus. A codebook was developed and refined iteratively as new insights emerged. Major code categories included: professional identity, emotional responses, coping strategies, family interactions, team dynamics, institutional factors, and meaning-making processes.
Continuum of Emotional Labor in Terminal Extubation
Continuum of Coping Strategies in Terminal Extubation
Continuum of Interactions During Terminal Extubation
Results
The two themes identified in this study, task-centered and event-centered, represent the two ideal types along the continuum. To illuminate how these orientations manifest in practice, we examine three analytical characteristics of participants’ experiences: emotional labor, coping strategies, and interactions with families and teams. These characteristics are not themes in themselves but rather dimensions through which the two ideal types are explored and contrasted. It is important to emphasize that these orientations are not fixed or universal across all situations. An RT may adopt a task-centered approach in one context yet lean toward an event-centered orientation with another patient, depending on the unique circumstances and dynamics at play. While individual practitioners may have personal preferences or dominant tendencies, their style often adapts in response to the specific context, patient, and family needs they encounter in practice.
Furthermore, the two ideal types, task-centered and event-centered, satisfy Thorne’s interpretive description criteria for meaningful theme development. Rather than simply labeling topical categories, these constructs capture the inherent conflict between technical detachment and emotional engagement, the irony of clinicians performing life-ending procedures without authority over the decisions that precede them, and the emotional texture of navigating profound human experiences within constraining institutional structures. The tension between these two orientations reflects the lived contradictions at the heart of RTs’ end-of-life practice.
Emotional Labor
Emotional labor refers to the effort required by healthcare professionals to regulate and manage their emotions to meet the expectations of their role, particularly during ethically and emotionally charged situations like terminal extubation. For RTs, this labor often involves balancing the technical demands of withdrawing life support with the profound emotional realities faced by patients, families, and the care team. As participants described, this work could entail either suppressing personal feelings to maintain composure and uphold a sense of professionalism or embracing vulnerability as a means of offering authentic compassion and support. The extent and ways emotional labor was performed are shaped by the therapist’s orientation, whether task-centered, where emotional expression was often restrained in favor of procedural focus, or event-centered, where emotional engagement was seen as integral to providing meaningful care. Ultimately, emotional labor in this context highlights the complex interplay between professional responsibilities and the human experience of loss.
Task-Centered Orientation: Suppression and Professional Composure
For RTs with a task-centered orientation, emotional labor during terminal extubation was often characterized by efforts to suppress or compartmentalize feelings to prioritize technical precision and procedural clarity. This suppression was often not experienced as a purely personal choice but as a response to norms absorbed during training and reinforced by workplace culture. Amanda recalled being explicitly instructed, as a student, to perform emotional detachment: [We were told to] be very just matter-of-fact, and cold, don’t show emotion, don’t do anything, just go in there, let them know what you’re going to do, pull the tube, and then go ahead and leave. (Amanda)
This kind of explicit socialization into emotional detachment shaped how many RTs came to understand professionalism. Rather than reflecting neutrality, this stance involved a deliberate distancing from emotion that could become dehumanizing in practice. As one participant reflected, “You are sort of expected to be strong in this setting because it’s a part of your job,” noting that over time, “you eventually just start to get used to it” (Barbara). The expectation of emotional fortitude was thus both externally imposed and internally absorbed, creating a self-reinforcing pattern of suppression.
Another participant reflected on the necessity of internal regulation: Normally, I’ve just got to push it down, even if it were … something that made me sad or whatever that’s just got to go away for right now, until I’m done with my twelve hours. (Amanda)
What is notable here is the temporal dimension: Amanda does not deny the emotion but defers it until the end of the shift. This pattern of deferral, managing affect through postponement rather than resolution, appears throughout task-centered accounts and has implications for cumulative emotional burden, a point we return to in the Coping section.
As William described, there is an internalized pressure that “If I came in weeping or sobbing, it’s unprofessional and it doesn’t reflect well on me” even when the emotional weight of the situation is significant. However, Patricia shared that for much of her career she maintained “strict professionalism,” though she acknowledged that over time she found it more acceptable to show she was “moved by that,” as families appreciate compassion, but the priority remained professional detachment. Patricia’s trajectory is analytically important: it suggests that task-centered emotional labor is not always a stable orientation but one that may shift with accumulated experience and changing institutional norms around mental health.
Event-Centered Orientation: Empathetic Engagement and Shared Humanity
In contrast, the event-centered ideal type highlights emotional labor as a process of empathetic engagement and shared human experience, where the therapist acknowledges and navigates complex emotional terrain. For event-centered therapists, emotional engagement is not a lapse in professionalism but part of how they bear witness to the significance of the moment. This orientation became visible, sometimes unexpectedly, in the details that surfaced during clinical routines. Barbara described encountering an ordinary object that suddenly made the human stakes of the day irreversible: I went in anyways to do my morning assessment that day … As I was listening to this person’s chest, I noticed from the corner of my eye … a picture. And it was his two children. And they were young. They were probably between like five and seven years old. I saw that and just started crying. It’s sad to know that these people will lose their parent today. (Barbara)
This moment is analytically significant in several ways. Barbara was not in the room for an emotional encounter; she was completing a routine morning assessment. The photograph was incidental. What her response reveals is that event-centered emotional labor does not require a deliberate act of empathetic engagement; it can arise spontaneously when clinical proximity renders the human dimension of the dying process suddenly concrete. For Barbara, the patient was not only a case but a father whose children would be changed by that day.
Sandra also embodied this approach, saying, “If you start crying, I’m crying with you … Everybody, we’re crying together. I don’t care what it is.” Sandra’s framing is worth unpacking: her willingness to cry with families is not a failure of composure but a deliberate relational stance, an offering of companionship in grief that she has clearly reflected on as a legitimate aspect of care.
As Lisa explain, “I’m crying tears of sadness for the family because of their loss, and I understand what loss feels like.” Lisa’s formulation draws a direct line between her own life experience of loss and her capacity for clinical empathy, illustrating how personal history is recruited consciously or not, into the emotional work of end-of-life care. Rather than suppressing these resonances, event-centered therapists mobilize them as relational resources.
Coping
The enactment of terminal extubation is inherently and deeply emotionally challenging for RTs. Regardless of whether they identify more closely with a task-centered or event-centered ideal type, many describe the experience as one that lingers beneath the surface during their shift, only to fully register once they are away from the immediate demands of patient care. As Emily reflected, “It usually strikes me only once I get home. I feel that I don’t really have the time to think or reflect about anything when I am at work.” This delayed surfacing of emotional impact is consistent across orientations and speaks to the structural reality that ICU workflows rarely allowed for in-the-moment processing. What distinguishes therapists is not the presence or absence of emotional impact but the strategies they use to manage it once it arrives.
Task-Centered Coping: Compartmentalization and Swift Transition
Task-centered RTs tend to compartmentalize terminal extubation as part of the procedural flow of their work. They demonstrate a notable ability to move swiftly from one patient to the next without lingering emotional disruption. For task-centered therapists, the capacity to return to ordinary life quickly to eat, socialize, and move on was not emotional shallowness but a practiced form of self-protection. Robert articulated this with striking candor: I feel sad, but I go to lunch … If somebody asked me how your day went, I would tell you that “We pulled a tube on somebody today and they died and the family was there. But let’s have dinner.” (Robert)
Robert’s narrative juxtaposition of death and dinner is not a dismissal of what occurred but a coping logic: the ability to name the event plainly and then return to the ordinary rhythms of life functions as containment.
A distinctive coping mechanism among task-centered therapists is the use of alcohol, particularly on the day of the terminal extubation. Matthiew shared candidly: “It usually doesn’t hit me till later … the enormity of it, cause it’s huge, a life just ended … So I just have a drink.” Similarly, Sandra reflected on the collective nature of this practice: “You’re probably going to find most of us at Fuzzy Tacos after a shift getting a beer-O-rita.” Susan also noted that following especially difficult cases particularly involving children or patients with whom she had formed a connection she would “come home and have, yeah, a glass of wine, which is not what I do normally.” The recurrence of this pattern across multiple participants, and its explicit framing as departing from everyday behavior, warrants attention as a potential indicator of cumulative stress rather than incidental social drinking.
When asked about formal debriefings, task-centered therapists generally expressed ambivalence rather than outright rejection. Their reluctance was less about denying the value of support and more about the timing mismatch between when debriefs were offered and when they were emotionally relevant. As one participant summarized the sentiment: “I’m not one to go to a lot of debriefings and I just feel like I … I guess I put it in the back of my mind, and I just move on to my next thing on the list that I must do or that must be done, or I go to my next patient. I know in the end it’s probably not the best thing to do that and to keep it all in, but for me, that’s how I cope” (Margeret). Critically, Margaret’s self-aware aside “I know in the end it’s probably not the best thing” signals that this is not a settled equilibrium but a recognized compromise. Susan expressed a similar logic: if the debrief is offered the following day, she attends; if it is delayed by a week, she has already moved on and does not wish to reopen what has been closed. This temporal sensitivity has practical implications for how support structures are designed.
Event-Centered Coping: Connection, Processing, and the Need for Institutional Space
Event-centered therapists, by contrast, experience terminal extubation as a profound ethical and relational encounter, making it harder for them to immediately shift focus to other patients. They often need space and connection to process the experience. Joshua described his approach: “I would try to call my team lead and let them know, that I’ll need a few minutes … I’ll go into the break room and just have a cup of water … try to decompress that way before I go into another patient’s room.” Joshua’s description reveals both the strategy and its precondition: he actively communicates his need to a team lead, which required an institutional culture that normalizes such requests. Where that culture did not exist, event-centered therapists find themselves absorbing the emotional weight without any legitimate outlet.
Event-centered therapists consistently expressed that they would deeply appreciate and benefit from debriefings. However, these supports were rarely prioritized by their institutions. Emily captured the frustration: “Me and the nurse left the ICU for a bit to take our time. I did request for debriefing and the administration said that they had already done it, without us, the shift that was involved in the withdraw, part of the discussion. This was a traumatic event, and they stick.” Emily’s account reveals a double institutional failure: not only was the debrief held without the people most directly involved, but the omission was apparently unnoticed or disregarded by administration. The phrase “they stick” points to the lasting psychological trace of an event that was never processed in community.
Dorothy also explains, “But a lot of the times, respiratory—you’ve got too many other patients, you’ve just got to … go to the bathroom, get it out, go on your next one. It wasn’t like you had time to go [to debriefing].” Dorothy’s account points to a structural rather than a cultural barrier: even when debriefing is available, staffing ratios mean that RTs cannot always leave their patient assignments to attend. This suggests that simply offering debriefing as an institutional resource was insufficient; adequate staffing coverage must accompany it.
Interactions
What emerges in practice is not a simple binary between task-centered and event-centered RTs but rather a fluid continuum shaped by the complex realities of contemporary healthcare. Patient-centered care, a widely promoted ideal in modern clinical practice, referred to an approach that respects and responds to the values, needs, and preferences of patients and their families. It emphasized shared decision-making, holistic understanding of the patient as a person rather than a case, and fostering dignity, empathy, and inclusion throughout care. Similarly, interdisciplinary collaboration promoted mutual respect, shared responsibility, and open communication among healthcare professionals to ensure cohesive and ethically sound care.
This positioning along the continuum profoundly shapes their interactions with both families and team members. A task-centered orientation often manifests in minimal engagement with families beyond technical duties and limited communication with team members outside familiar, procedural exchanges. In contrast, an event-centered orientation fosters active involvement with families, offering explanations, guidance, and emotional support, and confident participation within the interdisciplinary team, including advocating for the patient’s wishes, contributing to decision-making, and engaging in ethical dialogue. Thus, where an RT situates themselves along this continuum determines not only how they perform terminal extubation but how they connect, communicate, and collaborate in these critical moments of care.
Task-Centered Therapists: Family Interactions
Task-centered RTs tend to adopt a role where they see themselves as responsible primarily for the technical and procedural components of terminal extubation. It is important to note that task-centered interactions with families are not typically experienced by the RTs themselves as indifferent or uncaring. Rather, they reflect a bounded conception of the RT’s role: care is expressed through technical competence and procedural management, not relational dialogue. Mary’s account illustrates this logic clearly: So usually I just ask them to step behind the curtain … I turn the ventilator off, take the tube out and then put them on usually a high humidity mask … and then quickly get the family back in … Try to make it as peaceful a situation as we can. (Mary)
Mary’s explicit goal “a peaceful situation” is oriented toward the family, but her means of achieving it is procedural efficiency and a clean, calm scene rather than sustained relational presence. Similarly, Barbara describes meticulous attention to the patient’s post-extubation appearance: I always try to clean their face … so that it looks presentable and that the family can touch them and kiss them, and it will look like their family member while they’re passing. (Barbara)
Barbara’s gesture is tender and considered; it is technical care in the service of relational dignity. What distinguishes this from the event-centered approach is not the absence of care but its form: the RT expresses care for the family through care of the patient’s body rather than through direct engagement or conversation. Task-centered therapists may view themselves as external to the event’s emotional and ethical dimensions, yet their actions were often quietly oriented toward the family’s experience.
Task-Centered Therapists: Interprofessional Team Interactions
In terms of team interaction, task-centered therapists may feel uncomfortable engaging beyond their familiar relationships. The discomfort of task-centered therapists with challenging hierarchical dynamics often produces a particular form of moral distress: the experience of watching clinical decisions they privately disagree with, without the relational resources or institutional legitimation to intervene. Dorothy described a case in which she believed a patient was being kept on ventilation unnecessarily: You just kind of sit there going, “Why are you doing this? You should just stop.” But, you know, I’m not the doctor. I can’t say that. (Dorothy)
Dorothy’s reasoning “I’m not the doctor” is not simply deference but a deeply internalized role boundary that forecloses advocacy before it is attempted. Crucially, this constraint is not absolute: as the event-centered accounts below illustrate, some RTs do challenge physicians in such moments. The difference lay not in clinical knowledge or ethical awareness but in the professional confidence and institutional permission that therapists perceive themselves to have. For task-centered therapists, the absence of explicit inclusion in decision-making processes reinforces the sense that their perspective is not sought and that speaking out carries professional risk.
Event-Centered Therapists: Family Interactions
In contrast, event-centered RTs fully embrace their role as active participants in both family and interdisciplinary team interactions during terminal extubation. Their approach is shaped by a deep commitment to patient- and family-centered care, coupled with a sense of professional agency and ethical responsibility. Furthermore, their active presence during terminal extubation offers them a sense of closure and moral clarity. Betty reflected, “I feel like being part of it all and being able to speak with the family and help with end-of-life care does provide a lot of closure for me … I just feel like I can have some closure and be able to let it go as well as it’s helping the families.” Betty’s account is notable because it makes explicit the bidirectionality of this engagement: being present with families is not experienced as an additional emotional burden but as a source of resolution. Engagement and closure were experienced as mutually constituting rather than closure coming only from detachment.
Susan similarly expressed that hearing directly from the patient or witnessing the family discussions legitimizes the action in her mind and heart. Susan worked at a small community hospital where she made a personal practice not required by policy of attending family meetings when the physician spoke with families about withdrawal. She described one specific case in which this practice led to direct advocacy. Susan described a case involving a patient with severe chronic respiratory illness who had been intubated, extubated, and re-intubated multiple times. The patient had become progressively weaker with each cycle. During rounds, the patient, while awake and alert on the ventilator, had clearly stated to the physician, the nurse, and Susan that they did not wish to be re-intubated again. The following day, however, when the patient’s son was present and indicated he wanted “everything” continued, the physician appeared to accept the son’s position without returning to what the patient had said the day before. Susan and the nurse, who had both been present for the patient’s own statement, intervened: So whenever the physician came out of the room from talking to the son and the patient, myself and the nurse said, “But that’s not what she said yesterday.” Where we told the doctor, like we told the physician, who was there yesterday, who heard it out of the patient’s mouth, doesn’t want this anymore. So the doctor went back in and had another conversation and specifically asked the patient … the patient said, “No, no more.” So the son was there to hear that. (Susan)
Susan and the nurse were not acting on opinion but on direct knowledge of the patient’s expressed wishes, which they had witnessed, and the physician had also heard but appeared to be setting aside in response to family pressure. The phrase Susan used, “that’s torture almost, to continue doing this to somebody,” was not rhetorical overstatement but a clinical assessment: this patient had experienced multiple rounds of intubation, bronchoscopy, and extubation, each leaving them weaker, and had explicitly said they were “tired” and did not want it repeated. Continuing would mean overriding both the patient’s stated wishes and their physical deterioration in response to family preference.
Event-Centered Therapists: Interprofessional Team Interactions
Event-centered therapists see themselves as integral members of the healthcare team, not merely as technicians executing a task. Susan emphasized the importance of being present during family meetings, not because it was mandated by policy but because of her personal commitment to ensuring ethical integrity: “I personally try to be present if the doctor is going to speak to the family members. I go into the room with the family, the physician, and the nurse, so that I, for myself, can understand what’s going on or know what’s going on, be a witness to what’s going on.” Susan is not claiming a formal decision-making role; she is claiming the right to be present, to hear, and to know, and it is this knowledge that enables the advocacy described above. Event-centered therapists thus expand their professional role not through formal authority but through presence and relational investment.
Betty similarly described her proactive role in team discussions, particularly in rural settings where RTs may have greater autonomy: “I make the point of being involved in family discussions as often as I can. Then when they discuss goals of care … I comment on it because respiratory plays a different role in all four [goals of care levels] and discuss that with the family.” Betty’s framing “respiratory plays a different role in all four” reflected a sophisticated understanding of how the RT’s clinical knowledge of ventilatory trajectories is not redundant with physician knowledge but complementary to it. Her involvement filled a specific knowledge gap that other team members cannot fill, and she articulates this clearly to families.
The rural context Betty describes is worth highlighting. Several participants in smaller or community hospital settings reported greater integration into team decision-making, more direct relationships with physicians, and more opportunities for both formal and informal advocacy. Melissa, also working in a smaller hospital, described the evolution of the team culture: “Over the years, you can see how it’s went from a hierarchical society to, okay, we’re a team aspect it’s patient-first.” This variation across institutional contexts confirmed that the degree of RT involvement in end-of-life decision-making was not a fixed feature of the profession but a function of institutional culture, staffing models, and relational history between professional groups.
In summary, coping, emotional labor, and interactions with families and teams vary in distinct ways between task-centered and event-centered RTs during terminal extubation. Task-centered therapists primarily emphasize procedural precision and seek to manage or contain emotional engagement, while event-centered therapists integrate the emotional and relational significance of the event into their practice, often facilitating more collaborative and supportive interactions.
Discussion
This study employed Weber’s concept of ideal types to examine how RTs navigate the complex terrain of terminal extubation, revealing a meaningful continuum between task-centered and event-centered orientations. The findings illuminate how institutional structures, professional socialization, and individual agency intersect to shape therapeutic encounters during one of medicine’s most profound moments, extending our understanding of professional identity and practice in end-of-life care.
Theoretical Contributions: Extending Weber’s Framework
The task-centered and event-centered ideal types that emerged from our analysis demonstrate how the same institutionally mandated procedure can be experienced and enacted in fundamentally different ways. The task-centered ideal type represents RTs who approach terminal extubation primarily through Weber’s instrumental-rational lens, focusing on technical execution and protocol adherence. This orientation reflects what might be characterized as protective distancing, where the broader existential significance of the act is minimized in favor of procedural competence.
The event-centered ideal type embodies RTs who perceive terminal extubation through a combination of value-rational and affectual orientations, understanding the procedure as an integral component of a meaningful end-of-life event. This orientation embraces the moral, relational, and emotional dimensions of the dying process, positioning the RT as an active participant in providing holistic care rather than merely executing technical tasks.
These findings extend Weber’s framework by illustrating how healthcare professionals can simultaneously embody multiple action orientations within a single clinical encounter. While terminal extubation may be formally structured as instrumental-rational action, the subjective experience of those performing it incorporates elements from all four of Weber’s action types, challenging simplistic categorizations of medical practice as purely technical or instrumental. More specifically, the extension lies in three moves: first, applying ideal-type analysis to a single discrete clinical procedure rather than to broad institutional forms, as in Weber’s original typology; second, demonstrating that a single professional can embody all four action types simultaneously rather than sequentially or exclusively; and third, showing that the tension between action orientations is not resolved by institutional role but actively negotiated by individuals in ways that vary by context, relationship, and accumulated experience. These contributions are relevant beyond respiratory therapy, offering a transferable analytic for understanding how clinicians across disciplines navigate procedures that are simultaneously technical, ethical, emotional, and relational.
Professional Identity and Moral Distress
The continuum between orientations reflects broader tensions within respiratory therapy, particularly regarding moral distress and professional marginalization. Both orientations appear to serve as adaptive responses to the moral complexity of participating in life-ending procedures without authority over decision-making processes, though each carries distinct psychological risks.
Moral distress, first conceptualized by Jameton (1984) as the experience of knowing the ethically appropriate action but being constrained from taking it, has since been documented extensively across healthcare disciplines (Epstein & Hamric, 2009). Task-centered therapists’ focus on technical execution while distancing themselves from ethical deliberation may represent a protective strategy against moral burden. This aligns with research identifying RTs as experiencing significant moral distress related to powerlessness in end-of-life decision-making (Houston et al., 2013; Piquette et al., 2023). However, our findings suggest this protective orientation may come at the cost of relying on potentially maladaptive coping mechanisms, including substance use. Epstein and Hamric (2009) concept of moral residue, the lingering distress that accumulates when morally distressing situations recur without resolution, is particularly relevant here: task-centered therapists who repeatedly compartmentalize rather than process these experiences may be accumulating a residual burden that surfaced in our data through escalating coping strategies such as alcohol use on difficult days. The distinction between moral distress and moral injury is also relevant in this context; where distress arises from constrained action, moral injury reflects a deeper rupture in one’s sense of moral integrity (Litz et al., 2009), and future research might usefully explore whether some RTs’ experiences cross this threshold.
Event-centered therapists, while more actively engaged in care’s moral dimensions, experience different forms of moral distress when institutional constraints limit their ability to provide holistic care. Their frustration with exclusion from debriefing sessions reflects broader organizational failures to provide adequate psychological support, contributing to what recent literature identifies as systemic factors in healthcare provider moral distress (Choi et al., 2023). Rushton (2016) concept of moral resilience, the capacity to sustain integrity and to engage ethically even under conditions of moral complexity, offers a productive framework for understanding the event-centered orientation: these therapists’ active engagement with the relational and ethical dimensions of care may represent not only a source of greater distress but also a resource for navigating it, provided that adequate institutional support is in place.
Implications for Interprofessional Collaboration
The differential team interaction patterns between orientations illuminate critical challenges in contemporary healthcare’s movement toward patient-centered, collaborative care models. Event-centered therapists’ willingness to engage in advocacy and challenge hierarchical dynamics reflects advanced interprofessional competencies, yet their experiences reveal persistent structural barriers to meaningful collaboration (McLaney et al., 2022). Research tracing the development of interprofessional collaboration over four decades identifies a recurring gap between rhetorical commitment to collaborative models and their structural enactment in clinical settings, with hierarchical role boundaries and professional silos proving particularly resistant to change (Paradis & Reeves, 2013). Our findings suggest that RTs’ exclusion from decision-making processes represents one manifestation of this broader and enduring pattern.
The systematic exclusion of RTs from family conferences and ethical discussions represents what recent scholarship identifies as professional marginalization that undermines both provider well-being and care quality (Heradstveit et al., 2023). This exclusion is particularly problematic given that RTs perform the physical act ending ventilatory support, suggesting a disconnect between responsibility and authority that may contribute to moral distress across both orientations. The interprofessional competency frameworks developed by the Interprofessional Education Collaborative (American Association of Colleges of Pharmacy & American Association of Colleges of Osteopathic Medicine, 2011) explicitly identify roles and responsibilities clarity, values and ethics, and interprofessional communication as foundational collaborative competencies, all of which our data suggest are inconsistently realized in the RT’s end-of-life role. Addressing this gap requires not only individual-level training but the institutional commitment to restructure team processes so that RT expertise is actively solicited, a point supported by systematic evidence that interprofessional collaboration produces improved professional practice and healthcare outcomes when meaningfully implemented (Reeves et al., 2017).
Organizational Support and Policy Implications
Perhaps most concerning is the inconsistent availability of psychological support for RTs involved in terminal extubation. The exclusion of RTs from debriefing sessions while including other healthcare professionals represents a significant organizational equity issue that may contribute to burnout and turnover. Research on critical care nursing has documented high rates of post-traumatic stress disorder and burnout syndrome in ICU clinicians (Mealer et al., 2009), and our findings suggest that RTs, despite their direct role in life-ending procedures, are often excluded from the support structures that exist for other members of the same team. This finding suggests that healthcare institutions have not fully implemented trauma-informed support frameworks despite growing recognition of their importance (Harder et al., 2021). The Critical Incident Stress Debriefing literature identifies timely, structured, and inclusive post-event processing as a key mechanism for mitigating acute stress responses in first responders and clinical staff (Everly, 1995); the exclusion of RTs from these processes is therefore not only an equity issue but a clinical risk management failure. Equally important is the organizational precondition for any such support to function: Edmondson (1999) foundational work on psychological safety demonstrates that team members will not disclose distress or seek support unless they perceive their environment as one where doing so carries no professional penalty.
Organizations should develop flexible support systems accommodating different professional orientations rather than one-size-fits-all approaches. Event-centered therapists clearly benefit from structured debriefing and emotional processing opportunities, while task-centered therapists may require alternative support mechanisms that respect their preference for compartmentalization while addressing potential risks of maladaptive coping.
Educational and Professional Development Considerations
These findings challenge respiratory therapy education to prepare students for both technical and relational dimensions of end-of-life care. Rather than promoting a single “correct” approach to terminal extubation, educational programs should help students understand the continuum of orientations while developing competence across both technical and interpersonal domains. The American Association of Colleges of Pharmacy and American Association of Colleges of Osteopathic Medicine (2011) core competencies for interprofessional collaborative practice provide a practical framework for this integration, identifying communication, teamwork, and ethical practice alongside clinical skills as foundational preparation for complex care environments. Embedding these competencies in respiratory therapy curricula, rather than treating relational skills as supplementary, would better equip graduates for the full scope of what terminal extubation demands.
Patterns related to national context, specifically, differences and similarities between Canadian and American participants, were observed in the data and are reported in a companion article currently in preparation.
Limitations and Future Directions
Several limitations should be acknowledged. The ideal types presented are analytical constructs that may not fully capture individual practitioners’ complexity, as real-world practice likely involves movement along the continuum depending on specific circumstances. Additionally, this study focused on RTs’ subjective experiences without examining patient or family perspectives on different approaches, representing an important area for future research.
The cultural and institutional contexts of Canada and the United States may limit generalizability to other healthcare systems. Future research should explore how different healthcare structures and cultural values shape therapeutic approaches to terminal extubation, and whether different orientations are associated with varying patient, family, or staff outcomes.
Conclusion
This study reveals that RTs’ experiences of terminal extubation extend far beyond technical competence, involving complex negotiations between professional identity, institutional constraints, and moral commitments. The task-centered and event-centered orientations represent valid adaptive responses to the unique challenges RTs face in end-of-life care, though each requires different forms of institutional support.
Understanding this diversity has critical implications for healthcare organizations, educational institutions, and policy development. Rather than privileging one orientation over another, healthcare systems must accommodate and support different approaches while ensuring all practitioners have resources necessary for providing compassionate, competent care. The systematic exclusion of RTs from decision-making and support processes represents a significant organizational failure requiring immediate attention.
As healthcare continues evolving toward patient-centered, interprofessional models, recognizing and supporting diverse ways in which professionals engage with end-of-life care becomes essential for both provider well-being and care quality. These findings suggest that supporting professional diversity while ensuring quality care represents both a challenge and opportunity for contemporary healthcare practice, requiring organizational commitment to equity, support, and recognition of all team members’ contributions to end-of-life care.
Footnotes
Acknowledgements
We thank the respiratory therapists who generously shared their time and experiences. We also acknowledge Point West for transcription support. Finally, we would like to thank the CSRT and Respiratory Breakroom for disseminating our recruitment poster.
Ethical Considerations
All procedures involving human participants were reviewed and approved by the University of Manitoba Health Research Ethics Board (HS22819 [H2019:181]).
Consent to Participate
All participants received a study information letter, had an opportunity to ask questions, and provided written informed consent prior to participation. The study complied with the ethical standards of the authors’ institutions and with the ethical principles outlined in the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2). No patient or family member participants were recruited for this study. Interview participants were licensed respiratory therapists who reflected on their professional experiences with terminal extubation. Because no identifiable patient data are reported, patient consent for publication was not required. All RT participants provided informed consent for participation and for the publication of anonymized quotations.
Author Contributions
Conceptualization: Study framing; Weberian ideal-type design; and end-of-life focus (LC). Methodology: Qualitative design; interview guide; and sampling strategy (LC, LS, and DK). Investigation: Participant recruitment and data collection (interviews) (LC, DK, and LS). Data Curation: Transcription oversight; data management; and de-identification (LC and DK). Formal Analysis: Coding; development of task-/event-centered continuum; and integration with Weberian theory (LC and LS). Validation: Analytic cross-checking and interpretive consensus meetings (LC, DK, and LS). Writing—Original Draft: Initial manuscript drafting (introduction, methods, results, and discussion) (LC). Writing—Review and Editing: Critical revisions for intellectual content and editing for journal style (LC, LS, and DK). Visualization: Figure/continuum schematic preparation (LC). Supervision / Mentorship: Scholarly guidance and methodological oversight (LC). Project Administration: Scheduling; regulatory documentation; and correspondence (LC). Funding Acquisition: Proposal writing, even if grant was not funded (LC).
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
This study generated qualitative interview data (audio-recordings and verbatim transcripts) from practicing respiratory therapists in Canada and the United States. Because participants discussed ethically sensitive end-of-life cases within small professional communities, sharing full transcripts publicly would compromise confidentiality. De-identified analytic excerpts are included in the manuscript. A minimally de-identified data subset (redacted transcripts and codebook) can be made available to qualified researchers for secondary analysis upon reasonable request to the corresponding author and contingent on (1) approval by the University of Manitoba Research Ethics Board (and any additional required institutional approvals) and (2) execution of a data use agreement safeguarding participant anonymity. Please contact Louise Chartrand (corresponding author) to initiate a request.
Permission to Reproduce Material From Other Sources
This manuscript contains only original material collected and created by the authors. No previously published tables, figures, or substantial text passages requiring permission have been reproduced.