Palliative Extubation in Critically Ill Patients: A Retrospective Study of Timing, Prior Expressions of Will, Sedation, and Outcomes.

Objective: To characterize palliative extubation (PE) as a clinical and ethical process in critically ill patients in a public hospital in Brazil, focusing on timing of palliative care (PC) involvement, shared decision-making, symptom management, and outcomes. Methods: This retrospective cross-sectional study included adult patients who underwent PE between January 2022 and December 2024. Data were obtained from a prospectively maintained institutional PC database and medical records. Variables included demographics, comorbidities, functional status, reasons for intubation, timing of PC consultation, family conferences, opioid use, palliative sedation, and outcomes. Descriptive analyses were performed. Results: Among 447 patients evaluated by the PC team, 122 (27.3%) underwent PE. The mean age was 69.7 years, and 51.6% were female. Half had a Palliative Performance Scale score ≤60 before admission. The mean time from hospital admission to PC consultation was 8.3 days. Family conferences were conducted in all cases (mean: 1.5 per patient), and extubation occurred within three days of the conference in 92.6%. Opioids were used in 77.0% of patients, predominantly morphine; palliative sedation was required in 21.3%, always with midazolam. In-hospital mortality was 91.8%, while 8.2% were discharged. Among deaths, 50% occurred on the same day as extubation, whereas others survived from hours to 31 days. Conclusions: In this cohort, PE was integrated into a structured, family-centered process involving interdisciplinary consensus and individualized symptom management. The variability in survival after extubation supports its interpretation as withdrawal of disproportionate treatment rather than an intervention intended to hasten death, underscoring the importance of early PC integration in intensive care settings.