1686: Palliative Extubation: Institutional Practices and Needs Assessment

Introduction: Palliative extubation (PE) describes removal of mechanical ventilation where death is expected and the goal is the patient comfort. As our institution does not implement formal training or protocols for PE, we sought to describe current PE practices in our medical intensive care units (MICU), improve end-of-life care, and identify opportunities to minimize psychological stress through structured surveys of staff members. Methods: We performed a cross-sectional survey of physicians, advanced practice providers (APPs), nurses (RNs), and respiratory therapists (RTs) at our institution. Quantitative items assessed experience, clinical decision-making, and institutional support. Qualitative responses were analyzed thematically and compared by role. Results: 55 physicians/APPs and 19 RNs/RTs participated. Over half reported >5 years ICU experience and most had participated in >10 PEs. This experienced cohort reported comfort during a PE (mean 4.31/5 physician/APP, 4.63/5 RN/RT) and well-controlled patient symptoms >75% of the time (collated 97.3%). Yet, RNs/RTs expressed difficulty in identifying patients at risk for uncontrolled symptoms after PE; physicians/APPs noted challenges in managing complex PEs, including terminal wean and airway collapse. Among our RN/RT group, many (94.7%) did not regularly reference a formal protocol or receive dedicated training (89.5%), nor did our physician/APP group (72.7% and 54.5% respectively). Use of standardized protocols (collated 75.5%) and subject-specific training (collated 58.5%) were highest scoring among suggested interventions. Thematic analysis identified key concerns: symptom burden (Physician/APP 58.5%, RN/RT 42.1%); family expectations (58.5%, 63.2%); communication needs (35.8%, 47.4%). RNs/RTs more often emphasized team dynamics and interdisciplinary planning, while physicians/APPs focused on medication management and symptom control. Conclusions: MICU staff identified breakdowns in communication, inadequate training in identifying and managing complex PEs, high symptom burden, and misalignment with families as contributors to nonoptimal management in PE. Across roles, there was clear need and strong support for institutional protocols and targeted educational initiatives to support patients and team members during PE and end-of-life care.