PLACE LABEL HERE
WITHDRAWAL OF LIFE SUSTAINING TREATMENT
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
Does not apply to brain death (policy 520-12) or pregnant patients (policy 520-27)
Reason for withdrawal: ____________________________________________________________________
1. Consults: Palliative Care Nurse
Chaplain Services
 Social Work Services for Hospice referral if patient is medically stable for transport
2. Code Status: DNR/AND (Allow Natural Death): In the event of cardiac or respiratory failure/arrest, CPR
will NOT be performed. Cardioversion/defibrillation, intubation, ventilation, and emergency medications
used exclusively for resuscitation will NOT be utilized
3. Discontinue pulse ox, lab tests, and radiology exams
4. Discontinue telemetry/monitoring after patient is on room air. Discontinue vital signs
5.  Discontinue tube feeding and/or parenteral nutrition
6. Discontinue lines not needed for medications or fluids
7. Initiate Comfort Care Orders (form # 3127) if patient survives extubation and will be transferred out of ICU
VENTILATION:
8.
Check one:
9.
 Immediate Extubation:
 Terminal Wean
 to room air OR
 O2 per nasal cannula for comfort
Titrate sedation and analgesia up in response to discomfort/distress during the weaning
process. If for any reason, appropriate titration is restricted, extubate immediately
Initial ventilator setting: IMV rate_______PS level_______FiO2________PEEP______
Reduce ventilator alarms to minimum settings
Reduce FiO2 to room air and PEEP to zero over 5 min
 Decrease IMV to 4 OR
 PS to 5 over 5 to 20 min as indicated by level of distress
When patient is comfortable on IMV rate 4 OR PS of 5, place on T piece with room air
Allow 10 min on T piece prior to removal of endotracheal tube
 Extubate patient to room air
 O2 per nasal cannula for comfort
SEDATION AND ANALGESIA:
10.  Discontinue paralytics and delay extubation until clinician confirms that the patient has sufficient motor
activity to demonstrate discomfort
11.
Do not discontinue current analgesia/sedation medications
INTERMITTENT PRN MEDICATIONS
12. To keep respiratory rate < 25/min and prevent signs or symptoms of pain/respiratory discomfort:
 Morphine 1-4 mg IV q hour prn
OR  Fentanyl 25-100 mcg IV q hour prn
13. Anxiety or Agitation:
 Ativan (lorazepam) 0.5-2 mg IV q 4 hrs prn
OR  Versed (midazolam) 2-5 mg IV q 1 hr prn
14. If able to prevent signs/symptoms of distress and discomfort with boluses more than 2 hrs apart, continue
to administer intermittent sedation. If patient requires boluses more frequently than q 2 hrs, call physician
(consider change to continuous sedation)
Order writer’s initials _______
Send copy to pharmacy
*4-3125*
FORM 4-3125 REV. 09/2013
Page 1 of 3
PLACE LABEL HERE
WITHDRAWAL OF LIFE SUSTAINING TREATMENT
ORDERS
Reference Page
Principles for Withdrawing Life Sustaining Treatment:
1. Withdrawal of life sustaining treatment is a medical procedure that requires qualified physician
participation.
2. Withholding treatment is morally and legally equivalent to withdrawing treatment.
3. When one life sustaining treatment is withheld, strong consideration should be given to withdrawing other
life sustaining treatments and changing the goal of care to comfort care.
4. Any treatment can be withdrawn including nutrition, fluids, antibiotics, blood products, and dialysis.
5. Death occurs as a complication of the underlying disease. The goal of palliative care outlined in this order
set and associated policy is to relieve suffering in a dying patient, not to hasten death. Actions solely
intended to hasten death are morally unacceptable, however, any dose of pain/distress relieving
medication can be used if required to provide comfort even if these doses may hasten death.
6. Concerns about hastening death by over-sedating patients are understandable. However, clinicians should
be extremely sensitive to the difficulties in assessing discomfort in critically ill patients and should be aware
that many patients develop tolerance to sedative medication. Therefore, clinicians should be wary of
under-treating discomfort especially during the withdrawal of life sustaining treatments in the ICU.
7. Patients should not have life support withdrawn while receiving paralytic drugs as these will mask signs of
discomfort. Life support can be withdrawn from patients after paralytic drugs have been stopped and
clinicians believe that the patient has sufficient motor activity to demonstrate discomfort.
FORM 4-3125 REV. 09/2013
REFERENCE PAGE
Page 2 of 3
PLACE LABEL HERE
WITHDRAWAL OF LIFE SUSTAINING TREATMENT
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
CONTINUOUS PRN MEDICATIONS
15.
Pain/Distress:
 Fentanyl 10 mcg/ml
Bolus: 25 mcg q 1 hr prn
Begin infusion at ____________mcg/kg/hr IV (consider initial rate: 0.05-5 mcg/kg/hr)
May titrate up 1 mcg/kg/hr prn to control or prevent pain/respiratory distress
If titration upward is necessary, give bolus first and then increase base rate
OR  Morphine 0.5 mg/ml
Bolus: 2-4 mg 1 hr prn
Begin infusion at ___________mg/hr IV (consider initial rate: 1-10 mg/hr)
May titrate up 1 mg q 30 min prn to control or prevent pain/respiratory distress
If titration upward is necessary, give bolus first and then increase base rate
16.
Anxiety/Agitation:
 Versed (midazolam) 1 mg/ml
Bolus: 0.5-2 mg IV q 30 min prn
Begin infusion at __________mg/hr IV (consider initial rate: 0.5-10 mg/hr)
May titrate up 1mg q 1 hr prn to control or prevent anxiety/agitation
If titration upward is necessary, give bolus first and then increase base rate
OR 
Ativan (lorazepam)1 mg/ml
Bolus: 0.5-2 mg IV q 4 hrs prn
Begin infusion at __________mg/hr IV (consider initial rate: 0.5-10 mg/hr)
May titrate up 1mg q 1 hr prn to control or prevent anxiety/agitation
If titration upward is necessary, give bolus first and then increase base rate
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
Physician signatures: see Withdrawal of Life Sustaining Treatment policy (520-27)
One signature required for withdrawal order for a non-pregnant adult with decision-making capacity or a
Durable Power of Attorney for Health Care who agrees with decision to withdraw life sustaining treatment.
Two physician signatures (one attending and one concurring) required for withdrawal order for non-pregnant
adult with applicable advance directives.
Three physician signatures (two of which have no interest in the outcome of the case) required for withdrawal
order for patient without decision making capacity or advanced directives but with available family.
Date ______Time _____Physician Signature _______________________________PID Number__________
Date ______Time _____Physician Signature _______________________________PID Number__________
Date ______Time _____Physician Signature _______________________________PID Number__________
Send copy to pharmacy
FORM 4-3125 REV. 09/2013
Page 3 of 3