From the Guidelines
Compassionate extubation should be performed with careful planning, including discussions with the patient's family, adequate symptom management, and administration of medications such as opioids and benzodiazepines to prevent distress, as recommended by the most recent guidelines on palliative care aspects in intensive care medicine 1. The process involves suctioning the airway, deflating the endotracheal tube cuff, and removing the tube, with ongoing assessment and management of symptoms, including dyspnea and anxiety, using medications such as opioids and benzodiazepines, and targeted sedation if necessary. Some key considerations for compassionate extubation include:
- Pre-extubation planning and discussion with the patient's family
- Administration of medications to prevent distress, such as opioids and benzodiazepines
- Suctioning the airway and deflating the endotracheal tube cuff before removal
- Ongoing assessment and management of symptoms, including dyspnea and anxiety
- Use of targeted sedation if necessary to reduce symptoms
- Emotional support for the patient and family throughout the process. The goal of compassionate extubation is to provide comfort and dignity during the dying process, and it should be performed by a physician with expertise in palliative care, with the support of a multidisciplinary team, as recommended by the guidelines on palliative care aspects in intensive care medicine 1.
From the Research
Definition and Purpose of Compassionate Extubation
- Compassionate extubation, also known as palliative extubation, is a procedure where mechanical ventilation is discontinued to honor the patient's preferences, optimize comfort, and allow a natural death when medical interventions are not achieving desired outcomes 2.
- The goal of compassionate extubation is to provide a peaceful and comfortable death for patients who are terminally ill or have a poor prognosis.
Clinical Scenarios and Ethical Considerations
- Compassionate extubation may be considered in clinical scenarios where patients are experiencing refractory symptoms that cannot be controlled by other means of medical management, and the withdrawal of life-sustaining treatment is deemed necessary 3.
- The Principle of Double Effect may be used to ethically justify the practice of palliative sedation and compassionate extubation, particularly in cases where the patient's death is imminent and the goal is to alleviate suffering.
Guidelines and Best Practices
- There is limited evidence on best practices for compassionate extubation, and the procedure is often done with much variability across the globe 2.
- However, some studies have provided guidelines for the process of compassionate extubation, including the use of the Respiratory Distress Observation Scale to ensure patient comfort during the procedure 4.
- A case-series study found that compassionate extubation can be safely and effectively performed in a community hospital setting, with a median time from extubation to death varying depending on the underlying disease 5.
Symptom Management and Palliative Care
- Symptom management is a critical aspect of compassionate extubation, and opioid, midazolam, and scopolamine may be used to induce transient sedation in terminally ill patients with respiratory emergencies 6.
- Palliative care teams play a crucial role in providing comprehensive care to patients undergoing compassionate extubation, including communication, planning, symptom assessment and management, and debriefing 2.