No good data exist to guide the process of withdrawal of invasive mechanical ventilation just prior to the end of life–variously known as “terminal extubation,” “compassionate withdrawal,” “extubation to comfort care,” et al. At most centers, once the decision is made by the patient or family, an opioid infusion is initiated, all non-palliative medicati…
I think that the spike of brain activity prior to death (which is fairly proven with near death studies) speaks to the need for opiates and speedy palliative extubation. Certainly if these patients become more alert just before death, they could experience pain and fear, as well as more pleasant emotions. Our job is to be sure that these patients don't suffer when their family makes a difficult decision to focus on comfort oriented care.