Ethics, communication and palliative care

Palliative symptom care and compassionate extubation

Reviewed Nov 2026·4 references
New· views rounded down, updated weekly

Comfort-focused care at the end of life: pain, breathlessness, agitation and secretions, and how to withdraw ventilation humanely.

Definition
When goals change to comfort, treat symptoms proactively and stop interventions that do not add comfort. Opioids and sedatives are titrated to relieve distress; the principle of double effect permits this even if death may be hastened.

At the bedside

  1. 1

    Assess symptoms

    Pain (CPOT/BPS), breathlessness (respiratory rate, accessory muscle use, grimacing), agitation, secretions; repeat at least hourly during withdrawal.

  2. 2

    Stop non-beneficial interventions

    Routine bloods, imaging, monitoring alarms, vasopressors, RRT, NG feeding that adds no comfort; keep mouth care, positioning and skin care.

  3. 3

    Pain and breathlessness

    Opioid (morphine or fentanyl) bolus and infusion titrated to comfort; fan and positioning.

  4. 4

    Anxiety and agitation

    Midazolam boluses/infusion; exclude urinary retention and pain.

  5. 5

    Secretions

    Reposition; glycopyrronium or hyoscine butylbromide; gentle oral suction; explain to family.

  6. 6

    Compassionate extubation

    Prepare family; premedicate (opioid ± midazolam) before extubation; stop neuromuscular blockers well before (must have worn off); reduce FiO₂/support then extubate to air or low-flow oxygen; treat distress immediately.

  7. 7

    After death

    Allow family time and rituals; bereavement support; complete death certification.

Breathlessness or pain

Morphine

IV/SC
Dose
1-2 mg IV (2.5-5 mg SC) as needed; infusion 0.5-2 mg/h
Worked example
70 kg opioid-naive: morphine 2 mg IV before extubation, then 1 mg/h infusion with 2 mg boluses for respiratory distress.

Anxiety, agitation

Midazolam

IV/SC
Dose
1-2 mg IV (2.5-5 mg SC) as needed; infusion 0.5-2 mg/h

Respiratory secretions

Glycopyrronium (glycopyrrolate)

SC/IV
Dose
200 mcg every 4-6 h as needed

Respiratory secretions (alternative)

Hyoscine butylbromide

SC/IV
Dose
20 mg every 4 h as needed (max 120 mg/24 h)
Red flag · call your senior now
Patient still paralysed with neuromuscular blockers when ventilation is withdrawn - unacceptable; stop NMB and confirm recovery first.
Pitfall
Giving large sedative doses with the stated aim of hastening death - document intent as symptom relief and titrate to symptoms.
Pitfall
Leaving monitors alarming at the bedside during dying.
Pearl
Ask the family about religious and cultural rituals (prayers, Ganga jal, last rites) and accommodate them in the ICU.

References

  1. 1

    Truog RD, Campbell ML, Curtis JR, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med 2008;36:953-63.

  2. 2

    National Institute for Health and Care Excellence. Care of dying adults in the last days of life (NG31). London: NICE; 2015.

  3. 3

    Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med 2014;370:2506-14.

  4. 4

    Davidson JE, Aslakson RA, Long AC, et al. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med 2017;45:103-28.

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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.