Indian Journal of Critical Care Medicine
Volume 28 | Issue 2 | Year 2024

Terminal Extubation or Terminal Weaning: Is it Feasible in Indian Intensive Care Units?

Arun Kumar1, Rajani S Bhat2, Raj K Mani3

1Department of Critical Care, Palliation, and Intensive Care Rehabilitation, Fortis Hospital, Mohali, Punjab, India

2Department of Interventional Pulmonology, Sparsh Hospitals, Bengaluru, Karnataka, India

3Department of Pulmonology and Critical Care, Yashoda Super Specialty Hospitals, Kaushambi, Ghaziabad, Uttar Pradesh, India

Corresponding Author: Arun Kumar, Department of Critical Care, Palliation, and Intensive Care Rehabilitation, Fortis Hospital, Mohali, Punjab, India, Phone: +91 9872828779, e-mail:

How to cite this article: Kumar A, Bhat RS, Mani RK. Terminal Extubation or Terminal Weaning: Is it Feasible in Indian Intensive Care Units? Indian J Crit Care Med 2024;28(2):103–105.

Source of support: Nil

Conflict of interest: Dr Raj K Mani is associated as National Advisory Board of this journal and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of the Editor-in-Chief and his research group.

Received on: 13 December 2023; Accepted on: 15 December 2023; Published on: 29 January 2024


Terminal extubation (TE) and weaning have long been suggested as a modality of intervention when the continuation of mechanical ventilation is not expected to achieve its therapeutic aim and is merely prolonging the dying process. The decision, however, is complex considering limited evidence regarding the best practices and is often defied due to inherent ethical, legal, and medical dilemmas. The article attempts a brief overview of available literature on this subject and discusses its feasibility in Indian intensive care units (ICUs).

Keywords: End-of-life care, Terminal weaning, Terminal extubation.


Terminal extubation (TE) and terminal weaning (TW) are well-recognized practices of withdrawal in palliative care and end-of-life care. The practice, however, is decried due to medicolegal and ethical dilemmas. The article attempts a brief overview of the available literature and assesses the feasibility of these practices in Indian intensive care units (ICUs).


The end-of-life decisions in an intensive care setting, continue to be widely debated for their legal and ethical ramifications. The practices vary, based upon the state legislations, and professional regulatory guidelines, and are often guided by the local hospital policy, physicians, and family preferences. The “foregoing of life support treatment” (FLST) is mostly offered with an understanding that the patient will eventually die from the underlying condition.

Terminal extubation and TW are well-recognized practices of withdrawal in palliative care and end-of-life care.1 These modalities are contemplated when mechanical ventilation is merely prolonging the dying process and its discontinuation simply allows nature to take its own course.

The practice of TE entails the removal of the endotracheal tube and discontinuation of mechanical ventilation to limit the prolonged suffering of the patient. Terminal weaning involves a reduction in tidal volumes, oxygen support, and positive end-expiratory pressure (PEEP) without the removal of the artificial airway.2,3 The patient may then continue to be maintained on minimal ventilation or placed on a t-piece with ongoing symptom-based care, eventually resulting in the demise of the patient.


Despite the general acknowledgment of FLST modalities in oncology services, TE and TW have found limited acceptance in nononcology ICUs. The decision is complex and often defied due to inherent ethical, legal, and medical dilemmas. A decade-old survey conducted across French ICUs revealed a preference for TW among two-fifth of the participating nurses and physicians.4 A recent survey regarding the practical aspects of end-of-life care, conducted across the Indian ICUs revealed that TW is practiced by 38% of the respondents whereas TE was offered by a mere 18%.5

As per the available literature, the intensivists consider these practices as emotionally distressing and show reluctance, being fearful of the fact that TE will result in sudden or acute demise.6 Plain speaking, even the proponents of “good death,” perceive these as unethical and often equate these to physician-assisted euthanasia. A greater acceptance of TW is probably due to a lesser moral burden on the physician and family as it is considered less intrusive than TE.7 Terminal extubation in an alert patient presents another gamut of psychosocial, ethical, legal, and procedural considerations.6


The reluctance to de-escalate/discontinue mechanical ventilation results in the patient being condemned on life support, despite a general acceptance that a good outcome is unlikely and the patient will eventually die despite the medical interventions. The families are thus left unsupported and forced to opt for a leave/discharge against medical advice. The respiratory support is then withdrawn en route or at home which is distressful both for the dying patient and the attending family members.


The available literature on the subject of TE and TW is contentious. There is available evidence that suggests complicated grief and lower satisfaction among the family members where the patient died while intubated.8,9 A recent systemic review by Efstathiou Nikolaos et al., on the available literature on terminal withdrawal of mechanical ventilation identified a wide variation in the clinicians’ practices and perceptions among countries and within countries.10 Thellier et al., while comparing TE and TW, reported improved satisfaction among the family members who opted for TE as they were present at the time of death of the loved one.3

A prospective observational multicentre study (ARREVE) was conducted across 43 French ICUs to assess the relative merits of TE vs TW from the perspective of patients and relatives. As per their findings, there was no difference in the psychological welfare of the relatives between the two groups. The patients who underwent TE were, however, noted to have more airway obstructions and gasps with immediate extubation, thus a suggestion was given towards a scope for refinement in palliation services. Immediate extubation on the contrary was documented to be associated with lesser job strain on ICU staff.11 Pragmatically speaking, TW has also been critiqued for prolonging the dying process and contributing to patient distress.2 The experience of the survivors of critical illness as to discomfort associated with endotracheal tubes and suctioning can be argued in favor of the removal of artificial airways.12

The dilemma leaves us with an unanswered question as to whether we can practice these modalities within the ambit of the existing legal framework or we must persist with a blanket refusal for the withdrawal of mechanical ventilation.

An essential component of this understanding is the fact that the purpose of both TW and/or TE is to honor and respect the patient or authorized surrogate’s decision that the mechanical ventilation must be withdrawn in the best interest of the patient as it may not be able to achieve its therapeutic goal.13 An explanation to the family that opting for TE/TW is “only with respect to limiting the life-sustaining treatments,” will help them make a pragmatic decision.

The proponents of TE and TW opine that, if we can accede to honor the family’s request to de-escalate inotropes or not to institute any further organ support (e.g., renal support), mechanical ventilation can also be withdrawn or de-escalated as this too is merely a support for the respiratory system.

Even from the perspective of medical ethics, an appropriate intervention is to start or continue a treatment whose benefit outweighs the risk or burden. It also implies that the treatment, which may be considered medically inappropriate, must be withheld or withdrawn. The withdrawals, while being difficult for the treating team, are more acceptable for the families, who have witnessed that the life support interventions haven’t delivered the desired positive outcome.14

The key to such a decision is effective communication. These conversations undoubtedly mandate reasonable knowledge and expertise and a consensus among all the stakeholders regarding the establishment of the terminal nature of the illness. The withdrawal must only be applied if the proposed comfort care pathway is well understood and accepted by all the members of the treating team and family. The rationale for change in the goals of treatment from cure to care along with the reassurances about the patient’s comfort, helps the family to decide on the best interest of the patient and avoids the inherent guilt associated with such decisions. Seeking the opinion of the hospital primary medical board and secondary medical board in compliance with the Supreme Court ruling will safeguard the physician from any subsequent legal liability.15 The conversations must also include the details of what is expected in the aftermath of such a decision, along with grief and bereavement support. A pre-emptive plan for symptom relief until death, needs to be discussed and documented as a part of the care plan. The presence of a senior member of the ICU team especially during the planned extubation (TE) has been found to be comforting for the ICU team and the family members.13


Terminal weaning and TE are ethical and clinically acceptable choices when chosen appropriately while prioritizing the best interests of a terminally ill patient. The ailing patient and their families may be offered either of these options without any preferential bias, with an understanding that death would be an inevitable outcome of the underlying pathological process.

The entire procedure requires collaborative decision-making which includes detailed family counseling, legally apt documentation, formalized institutional protocols and guidelines, symptom support to the dying patient, along emotional and bereavement support to the family members.


At this conjecture, discontinuation of mechanical ventilation may still be adopted by a limited number of intensivists but TW may find more supporters. There is an impending need for the constitution of the primary hospital medical board in every hospital to safeguard the interests of both the physicians involved and the family members. A discussion about TW and TE must also be included when an advanced directive is being prepared and also as a part of advanced care planning. A prospective survey on TE and TW practices in multiple centers across India is warranted.

The medicalization of death needs to be countered and the pedagogy of dying needs to be advocated to preserve the dignity of dying patients.


Arun Kumar

Rajani S Bhat

Raj K Mani


1. Kok VC. Compassionate extubation for a peaceful death in the setting of a community hospital: A case–series study. Clin Interv Aging 2015;10:679–685. DOI: 10.2147/CIA.S82760.

2. Truog RD, Campbell Ml, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, 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(3):953–963. DOI: 10.1097/CCM.0B013E3181659096.

3. Thellier D, Delannoy PY, Robineau O, Meybeck A, Boussekey N, Chiche A, et al. Comparison of terminal extubation and terminal weaning as mechanical ventilation withdrawal in ICU patients. Minerva Anestesiol 2017;83(4):375–382. DOI: 10.23736/S0375-9393.16.11468-3.

4. Cottereau A, Robert R, le Gouge A, Adda M, Audibert J, Barbier F, et al. ICU physicians’ and nurses’ perceptions of terminal extubation and terminal weaning: A self-questionnaire study. Intensive Care Med 2016;42(8):1248–1257. DOI: 10.1007/s00134-016-4373-9.

5. Kumar A, Sinha S, Mani RK. A survey for assessment of practical aspects of end-of-life practices across Indian intensive care units. Indian J Crit Care Med 2023;27(8):531–536. DOI: 10.5005/jp-journals-10071-24500.

6. Billings JA. Humane terminal extubation reconsidered: The role for pre-emptive analgesia and sedation. Crit Care Med 2012;40(2):625–630. DOI: 10.1097/CCM.0b013e318228235d.

7. Campbell ML, Carlson RW. Terminal weaning from mechanical ventilation: Ethical and practical considerations in patient management. Am J Crit Care 1992;1(3):52–56. PMID: 1307907.

8. Kentish–Barnes N, Chaize M, Seegers V, Legriel S, Cariou A, Jaber S, et al. Complicated grief after death of a relative in the intensive care unit. Eur Respir J 2015;45(5):1341–1352. DOI: 10.1183/09031936.00160014.

9. Hinkle LJ, Bosslet GT, Torke AM. Factors associated with family satisfaction with end-of-life care in the ICU: A systematic review. Chest 2015;147(1):82–93. DOI: 10.1378/chest.14-1098.

10. Efstathiou N, Vanderspank–Wright B, Vandyk A, Al–Janabi M, Daham Z, Sarti A, et al. Terminal withdrawal of mechanical ventilation in adult intensive care units: A systematic review and narrative synthesis of perceptions, experiences and practices. Palliat Med 2020;34(9):1140–1164. DOI: 10.1177/0269216320935002.

11. Robert R, Le Gouge A, Kentish–Barnes N, Cottereau A, Giraudeau B, Adda M, et al. Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study). Intensive Care Med 2017;43(12):1793–1807. DOI: 10.1007/s00134-017-4891-0.

12. Turner JS, Briggs SJ, Springhorn HE, Potgieter PD. Patients’ recollection of intensive care unit experience. Crit Care Med 1990;18(9):966–968. DOI: 10.1097/00003246-199009000-00012.

13. National Ethics Teleconference terminal extubation: Ethics perspectives March 30, 2005. Available from: Accessed on: 22 November 2023.

14. Australian and New Zealand Intensive Care Society. ANZICS statement on care and decision‐making at the end of life for the critically ill, edition 1.0. Melbourne: ANZICS; 2014. Available at: Accessed on: 30 April 2023.

15. Mani RK, Simha S, Gursahani R. Simplified legal procedure for end-of-life decisions in India: A new dawn in the care of the dying? Indian J Crit Care Med 2023;27(5):374–376. DOI: 10.5005/jp-journals-10071-24464.

© The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.