TRACH-Support: A Conversation Tool for Tracheostomy and Prolonged Mechanical Ventilation

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What are the options when my loved one cannot come off the breathing machine?

Click on each option for more information. Remember, not all options are possible for every patient. Talk to the medical team to understand which options are possible for your loved one.

Possible Long-Term Ventilator and Life-Support

Long-Term Tracheostomy

Tracheostomy Time Trial

Trial Extubation (tracheostomy backup)

Focus on Comfort Without Machines or Long-Term Life Support

Extubation with DNR/DNI

Comfort-Only Focused Approach
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The Patient decision aids on this website are licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.The material provided on this website is for informational purposes only and is not provided as medical advice. Nothing contained in these pages is intended to be for medical diagnosis or treatment. Any individual should consult with his or her own physician before starting any new treatment or with any question you may have regarding a medical condition. No personal health information will be collected from users. Contact information is only collected if the user requests additional information regarding one of the tools. Last Updated 10/31/2019

Funding by the National Institutes on Aging (1K23AG040696) and the Patient-Centered Outcomes Research Institute (PI000116-01).

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Click through the rest of the decision-aid to learn more about tracheostomy

  • In a tracheostomy time trial the family agrees to proceed with a tracheostomy.
  • Recognizing that some patients may not recover, the family sets a time limit on how long they want to try life support. For example, some families may want to give their loved one a month or two months to recover
  • If a person does not recover in that time frame, the family would transition to a comfort-only focused approach, disconnecting the life support machine. However, many families say it is harder to stop life support than it is to say no to a tracheostomy.
  • For patients close to coming off the breathing machine, an alternative to tracheostomy can be trial extubation.
  • A trial extubation is when the breathing tube is removed to see if someone can breathe on their own.
  • If that patient cannot breathe on their own, the breathing tube is put back in the mouth. The patient would then need a tracheostomy to stay connected to the breathing machine for more time.
  • However, this can sometimes be dangerous. Some patients may get much sicker when trying to put the breathing tube back in the mouth. Therefore, trial extubations are not appropriate for all patients.
  • Extubation means disconnecting the breathing machine and removing the breathing tube in the mouth.
  • For patients who are close to being able to breathe on their own, families can choose to remove the breathing tube in the mouth with a Do-Not-Resuscitate/Do-Not-Intubate (DNR/DNI) order. The DNR/DNI order means that if a patient’s heart stops or they cannot breathe on their own, attempts to restart the heart (like pounding on the chest) or life support machines (like the breathing machine) will not be used.
  • In the Extubation with DNR/DNI approach, other medications (like antibiotics) are continued. If they patient is able to breathe on their own without the machine and tube, then other standard medical care like antibiotics will continue.
  • If a patient struggles to breathe on their own or other complications arise, then the focus of care shifts to comfort-only measures with the understanding that the patient will likely die (Comfort-Only Focused Approach).
  • A Comfort-Only Focused Approach means that the family decides not to pursue a tracheostomy. The family wants to focus only on keeping the patient as comfortable as possible knowing that they will likely die soon.
  • Often this pathway involves starting new medications for comfort and stopping medical therapies that do not add to comfort.
  • Typically, the breathing tube is removed and many families describe the process as “letting nature take its course” or letting a loved one “die naturally”.
  • All measures are focused on keeping the patient comfortable and ensuring they do not suffer.