Abstract
Objective:
To characterize palliative extubation (PE) as a clinical and ethical process in critically ill patients in a public hospital in Brazil, focusing on timing of palliative care (PC) involvement, shared decision-making, symptom management, and outcomes.
Methods:
This retrospective cross-sectional study included adult patients who underwent PE between January 2022 and December 2024. Data were obtained from a prospectively maintained institutional PC database and medical records. Variables included demographics, comorbidities, functional status, reasons for intubation, timing of PC consultation, family conferences, opioid use, palliative sedation, and outcomes. Descriptive analyses were performed.
Results:
Among 447 patients evaluated by the PC team, 122 (27.3%) underwent PE. The mean age was 69.7 years, and 51.6% were female. Half had a Palliative Performance Scale score ≤60 before admission. The mean time from hospital admission to PC consultation was 8.3 days. Family conferences were conducted in all cases (mean: 1.5 per patient), and extubation occurred within three days of the conference in 92.6%. Opioids were used in 77.0% of patients, predominantly morphine; palliative sedation was required in 21.3%, always with midazolam. In-hospital mortality was 91.8%, while 8.2% were discharged. Among deaths, 50% occurred on the same day as extubation, whereas others survived from hours to 31 days.
Conclusions:
In this cohort, PE was integrated into a structured, family-centered process involving interdisciplinary consensus and individualized symptom management. The variability in survival after extubation supports its interpretation as withdrawal of disproportionate treatment rather than an intervention intended to hasten death, underscoring the importance of early PC integration in intensive care settings.
Introduction
Although some deaths in the intensive care unit occur unexpectedly despite maximal support, many occur after withdrawal of life-sustaining treatments previously considered nonbeneficial. 1 In patients with irreversible progressive illness, maintaining invasive support without a realistic prospect of recovery may prolong dying in an undesired manner. When recovery is no longer possible and death becomes predictable, end-of-life care should prioritize relief of suffering, support for patients and families, and avoidance of futile measures. 2
Palliative extubation (PE), defined as the planned withdrawal of mechanical ventilation in patients with poor prognosis and no expectation of meaningful recovery, has gained increasing attention in intensive care settings. Despite its clinical and ethical relevance, high-quality evidence on PE remains limited, as highlighted by recent scoping reviews. 3
Studies suggest that many patients with advanced chronic illness would prefer not to be maintained on life-sustaining treatments under conditions of severe functional dependence. In a recent study, more than 80% of patients expressed a desire for withdrawal of invasive support in such scenarios, reinforcing the importance of aligning treatment decisions with patient values. 4
In critically ill populations, decisions regarding continuation or withdrawal of life-sustaining therapies are complex and often occur in the context of uncertainty, emotional burden, and limited prior planning. Early integration of palliative care (PC) has been associated with improved communication, increased completion of advanced care planning, and greater concordance between care delivered and patient preferences.5,6
In Brazil and other middle-income settings, the implementation of PE remains heterogeneous, with limited epidemiological data and variability in clinical practice. Understanding how PE is performed in real-world contexts, including timing, communication processes, symptom management, and outcomes, is essential to inform best practices.2,7
This study aimed to characterize palliative extubation as a clinical and ethical process in critically ill patients in a public hospital in Brazil, focusing on patient characteristics, timing of PC involvement, shared decision-making, symptom control strategies, previously expressed wishes, and outcomes.
Methods
This retrospective cross-sectional study was conducted in a public general hospital in Brazil and included all adult patients (≥18 years) who underwent palliative extubation between January 2022 and December 2024.
Palliative care consultation was requested by the Intensive Care Unit (ICU) physician in agreement with the attending physician and was not limited to decisions regarding treatment limitations but aimed to provide comprehensive assessment, symptom management, and support for patients and families.
All patients were evaluated by a board-certified palliative care physician through medical record review, bedside assessment, multidisciplinary discussion, and structured family conferences. The decision to proceed with palliative extubation was based on shared decision-making involving the ICU team, palliative care team, and the patient or legal surrogate.
Family conferences were conducted by the palliative care physician and a psychologist, typically after prior multidisciplinary consensus. A structured approach was used, including emotional validation, exploration of values and preferences, clarification of prognosis, alignment of expectations, and shared decision-making. All meetings were documented in the medical record.
Palliative extubation was conducted according to a formal institutional protocol, approved by the hospital’s bioethics committee and clinical leadership, ensuring standardized decision-making, preparation, and execution of the procedure. The protocol recommends withdrawal of mechanical ventilation in patients with severe, incurable, and/or irreversible conditions when continued ventilatory support is no longer consistent with the established goals of care and when there is agreement from the patient or their legal representative. The process includes a preparatory phase focused on symptom optimization and communication, gradual reduction of ventilatory parameters, and extubation with continuous monitoring and management of symptoms such as dyspnea, anxiety, and agitation, primarily using opioids and sedatives when required.
Data were obtained from a prospectively maintained institutional palliative care database and complemented by medical record review. Collected variables included demographic characteristics, comorbidities, functional status assessed by the Palliative Performance Scale prior to admission, reasons for intubation, prior palliative care follow-up, previously expressed wishes, timing of palliative care consultation, characteristics of family conferences, use of opioids, use of palliative sedation, and clinical outcomes.
Reduced level of consciousness was defined as impaired neurological status prior to sedation, typically present before intubation and constituting one of the indications for airway protection and initiation of mechanical ventilation. Irreversibility was determined on a case-by-case basis by the ICU and attending physicians after therapeutic failure and/or recognition of an advanced and nonreversible underlying condition.
Primary outcomes included in-hospital mortality and time from extubation to death, while secondary outcomes included hospital discharge and location of death. Descriptive statistical analyses were performed.
Results
During the study period, 447 patients were evaluated by the palliative care team, of whom 122 (27.3%) underwent palliative extubation (Fig. 1). The mean age was 69.7 years, and 51.6% were female. Most patients had significant comorbidities, including hypertension (48.4%), dementia (31.1%), diabetes (30.3%), and heart failure (23.0%). Half of the patients had a Palliative Performance Scale score ≤60 prior to admission, indicating substantial functional impairment. Previously expressed wishes regarding limitation of life-sustaining treatments were identified in 33.6% of cases, primarily through family reports, with no formal advance directives documented.
Patient selection flow diagram.
The most common reasons for intubation were reduced level of consciousness (45.1%), acute respiratory failure (26.2%), sepsis (13.1%), postcardiac arrest (9.0%), and shock (6.6%). Among nononcologic patients, 17 had received prior palliative care follow-up. Family conferences were conducted in all cases, with a mean of 1.5 meetings per patient, always following multidisciplinary discussion. The mean time from hospital admission to palliative care consultation was 8.3 days, and extubation occurred within three days of the family conference in 92.6% of cases.
Opioids were used in 77.0% of patients, predominantly morphine, while palliative sedation was required in 21.3% of cases, always using midazolam. In-hospital mortality was 91.8%, while 8.2% of patients were discharged. Among those who died, 50% died on the same day as extubation (median 2 hours), whereas others survived from hours up to 31 days. Deaths occurred both in the ICU (67%) and in the ward (33%). Additional details are presented in Tables 1 and 2.
Baseline Characteristics of Patients Undergoing Palliative Extubation (n = 122)
COPD, Chronic Obstructive Pulmonary Disease; SD, Standard Deviation.
Clinical Characteristics, Process of Care, and Outcomes (n = 122)
Discussion
This study describes palliative extubation as a structured clinical and ethical process involving interdisciplinary consensus, family-centered communication, and individualized symptom management in a public hospital in Brazil. The findings highlight that PE is not an isolated technical act but part of a broader decision-making pathway aligned with patient values. These findings also contribute real-world data to a field still characterized by limited high-quality evidence on palliative extubation.2,3,8
The relatively late timing of palliative care consultation (mean 8.3 days) suggests an opportunity for earlier integration. Previous studies have demonstrated that early palliative care involvement is associated with improved advance care planning and greater alignment between treatments and patient preferences.5,6
A key strength of this study is the detailed description of family conferences, which played a central role in decision-making. The structured approach adopted, combining emotional support, clear communication, and shared deliberation, illustrates how autonomy in end-of-life care is often relational, constructed through dialogue among patients, families, and health care professionals.5,9
The absence of formal advance directives in this cohort contrasts with findings from countries where such practices are more established. Nevertheless, previously expressed wishes, identified through family narratives, were frequently incorporated into decision-making, reinforcing the importance of communication over documentation alone. 10
The variability in survival after extubation, including cases of prolonged survival and hospital discharge, supports the interpretation of palliative extubation as a withdrawal of disproportionate treatment rather than an intervention intended to hasten death. This finding aligns with ethical and clinical guidelines distinguishing palliative care practices from life-ending interventions and reinforces PE as a practice grounded in respect for patient autonomy and the ethical imperative to relieve suffering.3,11,12 The short interval between family conferences and extubation in most cases likely reflects not haste, but alignment between clinical judgment, patient values, and family understanding. As reported in previous studies, postextubation survival is influenced by factors such as functional reserve, underlying disease trajectory, and symptom management, further underscoring that the primary goal of PE is comfort-focused care within ethical boundaries.11,12
Symptom control was achieved predominantly with opioids, with palliative sedation required in a minority of cases. The consistent use of midazolam when sedation was indicated is in line with current recommendations for the management of refractory symptoms at the end of life.13,14
This study has several limitations, including its retrospective design and single-center setting, which may limit generalizability. Selection bias is possible, as only patients evaluated by the palliative care team were included, and not all patients eligible for palliative extubation were assessed, limiting conclusions regarding its overall utilization. Additionally, information bias may have occurred due to reliance on recorded data from medical records.
Conclusion
Palliative extubation, in this cohort, was conducted within a structured and ethically grounded process integrating palliative care consultation, multidisciplinary consensus, and family-centered communication. The findings reinforce its role as withdrawal of disproportionate treatment, guided by patient values and focused on relief of suffering.
Authors’ Contributions
R.M.S.: Study conception, data analysis and interpretation, discussion of results, drafting and critical revision of the manuscript, and final review and approval of the final version. F.G.V., M.A.G.S., and L.G.S.I.: Data collection, participation in data analysis and interpretation. M.P.: Data analysis and interpretation, discussion of results, and article drafting and/or critical revision.
Ethics Committee Approval
All ethical aspects were observed in accordance with Resolution 466/2012 of the Brazilian National Health Council. Anonymity, confidentiality, and privacy of collected data were guaranteed. The Free and Informed Consent Form was waived due to the retrospective and observational nature of this study, which was based solely on the analysis of previously recorded secondary data in medical records and in the institutional database of the palliative care service, without any direct intervention or contact with the participants. The study was approved by the Research Ethics Committee through Plataforma Brasil number 80049724.3.0000.5438.
Data Availability Statement
The datasets generated and/or analyzed during the current study are not publicly available due to ethical and confidentiality restrictions related to medical record information and potentially identifiable data. Anonymized data may be made available by the corresponding author upon reasonable request and prior approval from the institutional ethics committee, in accordance with current data protection regulations.
Footnotes
Acknowledgments
The authors thank all collaborators of the Santa Casa de Franca, São Paulo, Brazil.
Author Disclosure Statement
The authors declare there are no conflicts of interest related to this study.
Funding Information
No funding was received for this article.