When a person is on life support in the intensive care unit (ICU), the term “pulling the plug” refers to withdrawing life-sustaining treatment and allowing the person to die naturally. This is an emotional decision for families facing end-of-life care for a critically ill loved one. Understanding what happens after removing life support can help make this difficult choice a little easier.
Why would life support be withdrawn?
There are a few common reasons a family may decide to withdraw life-sustaining treatment:
- The person has an incurable condition and will not recover despite full medical treatment
- The person has little to no conscious awareness or ability to interact with the environment
- The person has expressed wishes not to be kept alive by machines or heroic measures
- The treatment is causing more burdens and pain than benefits for the patient
In these cases, the medical team and family may determine that continuing life support is no longer aligned with the patient’s values and goals of care. The focus shifts to allowing a natural death and maximizing comfort in the final stages of life.
What happens after withdrawing life support?
The sequence of events after life support is removed depends on the types of treatment being used. Here is a general timeline of what could occur:
- Immediately: sedative medications may be administered to prevent air hunger or distress. Analgesics help relieve any pain. The patient is kept clean, dry and repositioned for comfort.
- Within minutes to hours: the heart rate, blood pressure and breathing decline without cardiac and respiratory support. Little change may be outwardly apparent initially.
- Over hours to days: kidney function decreases without dialysis, body temperature lowers, and the patient becomes unresponsive as vital organs shut down. Congestion in the airways may cause noisy breathing.
- Death: the patient experiences cardiac and respiratory arrest as the body completely shuts down. Death is declared once breathing ceases, and there is no pulse. This can occur within minutes, hours or occasionally days after withdrawing aggressive life-sustaining therapy.
While the sequence can vary, the process is designed to allow death to occur gradually and reduce distress for the patient. Staff continually monitors for any signs of pain or discomfort and administers appropriate medications to ease the transition.
What kind of life support might be withdrawn?
Some common types of life-sustaining treatment that could be withdrawn include:
- Mechanical ventilation (breathing machine): removes this external respiratory support and allows normal breathing patterns to resume if possible or cease entirely.
- Vasopressors: discontinues IV medications used to increase critically low blood pressure in shock states.
- Dialysis: stops filtering of the blood to replace kidney function.
- Feeding tubes: removes artificial nutrition via tubes inserted through the nose into the stomach or directly into the small intestine.
- ICD (implanted cardioverter defibrillator): deactivates a device used to shock an abnormal heart rhythm.
- Pacemaker: turns off a device used to regulate heart rate and rhythm.
- ECMO (extracorporeal membrane oxygenation): discontinues use of a machine that oxygenates blood outside of the body.
Stopping these treatments allows the body to progress through natural stages of shutting down. Death does not occur immediately but does become inevitable without life support measures.
What palliative care is provided?
Even after withdrawing life-sustaining therapy, the focus remains on patient comfort and dignity. Palliative care provided typically includes:
- Medications for relief of pain, air hunger, excessive secretions or anxiety
- Frequent mouth care and lip moisturizing
- Position changes and gentle range of motion exercises for physical comfort
- Attendance to personal care needs like bathing and gentle skin cleansing
- Communication through soothing words or music, even if the patient is unconscious
- Emotional and spiritual support for family members as they keep vigil
The healthcare team continually monitors the patient and adjusts treatments to ease any signs of distress. The goal is to allow as peaceful and comfortable a death as possible once curative treatments stop.
What should family members expect?
The process of withdrawing life support and allowing death to occur is highly emotional for the family. Some things they may experience include:
- Sadness, anger, doubt or relief about the decision
- Guilt over giving up hope for recovery
- Uncertainty about how long it will take for death to occur
- Worry their loved one will suffer without full treatment
- Desire to remain close and do whatever they can to comfort the patient
- Feeling overwhelmed about losing their loved one
The medical staff and palliative care specialists help families through this difficult transition. Emotional and spiritual support is provided throughout the process. Family can participate in care as much or as little as they desire. Their loved one is kept clean, peaceful and dignified whether they remain at the bedside or take a respite.
Final steps after death occurs
Once death has been declared by the physician, the staff proceeds with several final steps:
- Monitors and tubes are respectfully removed from the body
- The family may wish to spend time together grieving with their loved one
- The body is washed and dressed for transfer to the morgue or funeral home
- Certification of death documents are completed
- Referrals may be provided for grief counseling, funeral arrangements, or other death care services
Withdrawing life-sustaining therapies is based on the principle of allowing death to occur naturally when a cure is no longer possible. While still difficult, families are often reassured their loved one did not suffer due to high-quality end-of-life care.
When is withdrawing life support appropriate?
There are some key considerations when deciding if removing life support aligns with a patient’s wishes and prognosis:
- The person’s condition is irreversible and incurable despite full medical efforts
- Quality of life is extremely poor with no hope of meaningful recovery
- The burdens of continued aggressive treatments outweigh any benefits
- Life support merely prolongs the dying process without improving health
- The person previously expressed desires not to remain on machines indefinitely
Ideally, these sensitive conversations occur proactively so the plan of care appropriately reflects the patient’s values if critical illness strikes. However, families are often faced with making difficult choices in the moment based on what they feel their loved one would want.
Key factors about when to withdraw life support
| Appropriate situations | Inappropriate situations |
|---|---|
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What are a patient’s rights regarding life support?
Patients have the following rights when facing decisions about continuing or withdrawing life-sustaining treatment:
- The right to sufficient information from doctors to make well-informed choices
- The right to access their medical records and test results
- The right to obtain a second opinion from another physician
- The right to have their advance directives for care followed
- The right to designate a surrogate decision-maker if unable to make their own choices
- The right to consent to or refuse treatments being offered
- The right to have an ethics committee review conflicts between providers and surrogate decision-makers
- The right to have cultural and spiritual beliefs and traditions respected
Even after the decision is made to allow natural death, patients still have all personal rights including respect, dignity, compassionate care focused on comfort, and freedom from pain or distress. A patient is never to be abandoned, even when treatment ceases.
What are a family’s rights regarding withdrawing life support?
Families also have important rights as they make choices about continuing or stopping life-sustaining therapies for their loved one. These include:
- The right to receive complete and understandable information about prognosis and options
- The right to access medical records in order to make fully informed decisions
- The right to have their grief respected and receive bereavement support
- The right to give advanced directives if named as surrogate decision-maker
- The right to request care such as analgesics that maximize comfort
- The right to refuse treatments they feel are unwarranted or futile
- The right to nursing care that protects the patient’s dignity, even at the end of life
- The right to an ethical review of any conflicts regarding goals of care
Families need ample support to decide whatRemove types of life support, if any, align with their loved one’s final chapter. Their rights help protect the interests of the patient.
What are the emotional impacts of withdrawing life support?
The choice to withdraw life-sustaining therapies also has intense emotional consequences. Families may grapple with:
- Sadness and grief: pain of losing a cherished loved one and preparing for life without them.
- Anger: frustration towards medical staff, the patient’s situation, or even the loved one for “giving up.”
- Fear: anxiety about whether choosing to withdraw support is ethically “right.”
- Guilt: questioning if enough was done to save the patient’s life.
- Relief: when a long dying process finally ends.
- Peace: spiritual comfort that the loved one is no longer suffering.
The intensity and variability of these emotions underscore the value of professional counseling before, during and after death. Many hospitals have palliative care teams that specifically help support families facing these difficult transitions.
Does insurance cover end-of-life palliative care?
Most insurance plans cover palliative and hospice services for terminally ill patients after withdrawing life support, including:
- Medicare Part A: covers hospice care if doctor certifies terminal illness.
- Medicaid: all state programs have hospice benefit with no copays or deductibles.
- TRICARE: military insurer covers hospice for families of active duty or retired members.
- Private insurers: most commercial plans include a hospice provision without need for pre-authorization.
Coverage applies whether the patient is at home or in a hospital or skilled nursing facility. Talk to your insurance provider about specific coverage details for end-of-life and palliative care services. Many also offer guidance on choosing hospice programs.
Coverage of palliative care services after withdrawing life support
| Insurance type | Palliative care coverage |
|---|---|
| Medicare Part A | Fully covered for hospice when terminal prognosis |
| Medicaid | Must provide hospice benefit without copays or deductibles |
| Military (TRICARE) | Includes hospice care provision for families |
| Private insurance | Most plans include hospice coverage without preauthorization |
What legal issues are involved?
Withdrawing life-sustaining measures does not legally constitute euthanasia or assisted suicide when done for ethically appropriate reasons. However, some legal issues families may encounter include:
- Obtaining court orders: if surrogate decision-makers and medical staff disagree, the court may need to resolve conflict.
- Writing a living will: this helps preserve patients’ wishes if they become unable to make their own medical decisions.
- Appointing a healthcare proxy: designating an advocate protects a patient’s autonomy if critical illness strikes.
- Probating a will: the patient’s death triggers legal processes around inheritance and estate settlement.
- Arranging care for dependents: parents need to designate guardianship for minor children after a death.
A probate and estate planning lawyer can advise families on managing legal issues before and after withdrawal of life sustaining treatment.
How can families cope with grief?
The intense grief after withdrawing life support and losing a loved one deserves as much care as that person received in their final days. Coping strategies include:
- Allowing oneself to fully grieve without judgment or timelines
- Speaking with a spiritual counselor about emotions and beliefs
- Participating in a bereavement support group
- Continuing bonds and connection through rituals like prayer
- Prioritizing self-care with rest, healthy eating and physical activity
- Letting others provide practical help and comfort
- Expressing feelings creatively through art, writing or music
- Considering grief counseling or therapy for persisting distress
The journey through loss when withdrawing life support is unique for each person. Supportive communities help families process these profound experiences.
Conclusion
Withdrawing life-sustaining therapies for a critically ill loved one is often fraught with emotion. Yet understanding the process and focusing on relieving suffering can make this decision a little more bearable. Honoring the patient’s values and wishes at the end of life, even when difficult, ultimately brings more peace than regret. The person’s healthcare providers, palliative care specialists, and estate planning experts form a compassionate team to support families through this transition.