Terminal extubation in 5 end-of-life patients in intensive care units

Introduction Decisions to withhold or withdraw active life support treatment in situations with no hope of improvement remain difficult for critical-care specialists and families; they are not always well understood by the public. This report describes terminal extubation, a particular method of withdrawing ventilator support. Methods This retrospective analysis examines the records of patients who died in our intensive care unit after a decision to withdraw active life support by stopping artificial ventilation. Extubation was proposed for patients with irreversible neurological damage and was always performed only after a standardized collective decision-making process. This process included three stages. In the initial phase, withdrawal of ventilator support was discussed at a department staff meeting. The meeting's conclusions were transcribed into the medical file, and the possibility of extubation was raised with the family during a planned interview. At least a 24-hour period of reflection was necessary before a new interview, and any opposition, hesitation or lack of understanding by the family at this first interview resulted in suspending the decision. The technical procedures for terminal extubation were also standardized. Results In 5 cases (4 men and one woman, with a mean age of 65 4 years), terminal extubation was decided in cooperation with the family, following an average of 3 interviews, 16 days after admission. All patients died within 3 days. Discussion So-called terminal extubation, very common in the United States, but much less so in France, reinforces the transparency of end-of-life decisions in intensive care units and immediately makes tangible the end of the aggressive treatment for which critical-care specialists have been reproached. Since this first series of patients, extubation has been practiced in our department, principally in situations of irreversible neurological damage.