End of life in the ICU: limitation of therapeutic effort, withdrawing the ventilator and comfort care
- Safe practice
When the team and family decide to limit treatment, the nurse prepares the patient and family, keeps comfort first and stays present until death.
What it is
In the ICU, many deaths follow a decision to withhold or withdraw treatments that no longer serve the patient's goals, such as the ventilator, vasopressors or dialysis. The decision is made by the physician with the patient or surrogate and the team, and is recorded; the ethics and law of that decision are on the linked ethics pages. Limiting treatment never means limiting care. The nurse's part is to prepare the room and the family, make sure comfort medicines are prescribed and ready, take part in removing the ventilator by terminal weaning or extubation as planned, treat breathlessness, pain, agitation and secretions, and support the family before, during and after the death.
What it requires
- The decision to withdraw is taken by the team with the patient or surrogate, consistent with the patient's values and goals.
- Units are advised to use protocols for sedation and analgesia during withdrawal of life support.
- Patients who undergo terminal extubation have more airway obstruction and gasping; families should be told what they may see.
- Terminal secretions usually appear in the last hours of life.
- Proactive palliative care consultation is suggested for selected critically ill patients.
How it is applied (and why)
- Confirm the decision, its record and the plan for each treatment: what stops, what continues and what will not be started — everyone must act on the same plan.
- Check that comfort medicines are prescribed and prepared before starting — symptoms can appear within minutes.
- Explain to the family, in simple words, what will be done and what they may see and hear — surprise adds to distress.
- Give the family time and space, and offer spiritual support (a chaplain or their own rituals) if they wish — spiritual needs are common and often unmet.
- Stop routine checks and procedures that no longer bring comfort — vital signs and tests can become a burden.
- During the planned weaning or extubation, watch the face, breathing and movements; give comfort medicines as ordered — relieve distress at once.
- For secretions, position the patient on the side and give the ordered medicine; avoid routine suctioning — it rarely helps and agitates.
- Stay present with the patient and the family — «providing presence» is part of nursing care.
- After death, give the family time, offer bereavement information, then do care of the body and any donation or legal steps — support goes on after death.
In nursing practice
- Assess pain in the unconscious patient through behaviour: grimacing, posturing, restlessness.
- Families can be tired and in crisis: repeat information and give it in writing when possible.
- Some clinicians prefer terminal weaning and others extubation; the choice follows the patient's condition and the plan agreed by the team.
- Withdrawal is emotionally hard for staff too; a debrief after the death helps the team.
Common mistakes
- Starting withdrawal before the comfort medicines are ready.
- Keeping routine vital signs and tests that only add burden.
- Suctioning terminal secretions repeatedly.
- Telling the family that «nothing more will be done»: care continues.
Test yourself
Think of the answer, then tap the question to see it.
What is the difference between terminal weaning and terminal extubation?
In terminal weaning the ventilator support is turned down and the tube stays; in terminal extubation the tube is removed.
What must be ready before the ventilator is withdrawn?
A recorded decision and plan, an informed family, and comfort medicines prescribed and prepared.
How are terminal secretions managed?
By turning the patient on the side and giving the ordered medicine; suctioning usually does not help and causes distress.
Does limiting life support mean limiting nursing care?
No. Comfort, symptom control, presence and support for the family continue until and after death.
Elsewhere in DurgiPedia
- Limiting life-sustaining treatment: withholding and withdrawing
- Medical futility and do-not-resuscitate orders
- Palliative sedation
- Advance directives (Documento de Voluntad Anticipada)
- Ley 1733 de 2014: palliative care
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Intensive care clinicians' experiences of palliative withdrawal of mechanical ventilation: a qualitative study (BMJ Open, 2025); Terminal extubation or terminal weaning: is it feasible in Indian intensive care units? (Indian Journal of Critical Care Medicine, 2024); New concepts in palliative care in the intensive care unit (Revista Brasileira de Terapia Intensiva, 2017); Nursing Fundamentals (Open RN), 17.5 Nursing Care During the Final Hours of Life (Open RN, Wisconsin Technical College System (LibreTexts, CC BY 4.0), 2021).
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Representative model, for educational purposes only.