Electronic Supplemental Material Appendix #2- Original Statements (Round 1) and
Strength of Evidence.
Section #1- Preparation for Withdrawal of Life Support
Original Statement
Level of Evidence
References
A patient-specific interprofessional care plan for the process of WDLS should
be outlined.
An experienced physician, bedside nurse and respiratory therapist must be
available to respond quickly to significant signs of distress at the time of
extubation.
The whole team should be present around withdrawals anticipated to be
difficult, including patients who are awake; patients receiving large amounts of
medications at baseline; patients with a high respiratory drive; cases where the
family or team are likely to become highly emotional.
Whenever possible, patients should be moved to a private room or curtains
drawn.
Visitation should be liberalized.
No
Recommendation
Suggest
-
No
Recommendation
-
Suggest
5-7
Suggest
5-7
Whenever possible monitors should be turned off in the room and shifted to
another screen.
The team should use an unobtrusive signal to alert the rest of the ICU that a
WDLS is in progress, in order to ensure a respectful and quiet atmosphere in
the vicinity.
Physicians must communicate with bedside nurse regarding the patient’s
comfort as required and to assist the interprofessional team in providing
palliative care.
Physicians must be readily available to assess and treat if new symptoms arise
after the team deems the patient comfortable.
The interprofessional team should be educated on acute bereavement
support.
A debriefing session for the interprofessional team should be considered on a
case by case basis. in particular after each difficult WDLS, when the team is
emotionally involved , or when new staff is involved.
A debriefing session should occur after a particularly challenging WDLS.
Suggest
3,5,6,8-10
No
Recommendation
-
Suggest
1,3,9
Suggest
1,3,9
Suggest
6,9-11
Suggest
4,11,12
Suggest
4,11,12
A patient’s desire to discuss WDLS should be acknowledged by the critical care
team and should occur in a responsive manner.
Members of the interprofessional team should be involved in discussions with
the patient and SDM/family regarding what to expect during WDLS.
The process of WDLS and the role of each team member should be outlined to
patients (when appropriate) and SDMs/families.
Discussions with patients (when appropriate) and SDMs/families should
include what to expect during the dying process (changes in vital signs, heart
rate patterns, breathing) and how signs of distress will be treated.
SDMs/families should be informed that time to death is variable and cannot be
predicted.
SDMs/families should be educated on physical signs and symptoms they may
witness.
SDMs/families should be educated on how pain and any other signs of distress
will be assessed and treated. [RECOMMEND]
All members of the interprofessional team play an important role in supporting
patients and SDMs/families at the bedside during WDLS.
No
Recommendation
Suggest
-
Suggest
15
Suggest
2,3,7,11,14
Suggest
2,7,11,14
Suggest
2,3,7,11,14
Suggest
2,3,7,11,14
No
Recommendation
-
1-4
11,13,14
Physicians should return to the bedside at regular intervals to ensure
emotional and psychological support of SDMs/families if appropriate.
SDMs/families should be allowed to be present during WDLS.
No
Recommendation
Suggest
-
SDMs/families should be allowed to participate in the care of patients during
WDLS.
SDMs/families should be encouraged to “be” with their loved ones and to
create ways of celebrating the person they love: including memory books,
expression of love, cultural and religious rituals.
A private quiet room should be made available to SDMs/families.
No
Recommendation
Suggest
10
No
Recommendation
No
Recommendation
Suggest
-
Whenever possible WDLS should incorporate ways to respect honour and/or
celebrate the uniqueness of the person who is the patient.
Patients and SDMs/families may be given an opportunity to contact their own
clergy or spiritual support.
Hospital spiritual care and/ or social work should be consulted and invited to
be present during discussions of WDLS process.
Young children of adult patients should receive particular attention and
support from the interprofessional team.
SDMs/families should be educated about the grieving process.
Suggest
1-3,7,9-11,14-23
No
Recommendation
Suggest
1
No
Recommendation
Suggest
-
SDMs/families should be offered acute grief support.
Suggest
6,9
SDMs/families should be offered a referral to community bereavement
services.
SDMs/families may be offered a future debriefing session with the physician
and/or interprofessional team.
SDMs/families should be sent a letter of condolence including bereavement
support information.
SDMs/families should receive a phone call from a member of the
interprofessional team a few weeks or months after the patient’s death in
order to see if they have questions and to assess their coping.
Critical Care units should develop resources outlining available resources for
grief and bereavement support including support groups in their area.
Suggest
6,9
No
Recommendation
No
Recommendation
No
Recommendation
-
No
Recommendation
-
SDMs/families should be allowed to stay overnight in the ICU.
Whenever possible, religious and cultural rituals should be facilitated.
5-7
3,7,9
5
1-3,7,9-11,14-23
1,3,5-7,10,11,1618,24
6,9,11
25
-
Section #2: Assessment of Distress
Original Statement
Level of Evidence
References
Pain should be assessed using a standardized scoring system.
Suggest
6,12,20,26
The standardized pain scoring system of choice is the Behavioral Pain Scale.
Suggest
6,12,20
The standardized pain scoring system of choice is the Pain Assessment Behavior
Scale.
The standardized pain scoring system of choice is the Critical Care Pain Observation
Tool.
The standardized pain scoring system of choice in pediatrics is the COMFORT scale.
No
Recommendation
Suggest
6
No
Recommendation
Suggest
-
No
Recommendation
No
Recommendation
No
Recommendation
No
Recommendation
No
Recommendation
No
Recommendation
No
recommendation
No
Recommendation
No
Recommendation
No
Recommendation
No
Recommendation
No
Recommendation
No
Recommendation
Suggest
28
No
Recommendation
No
Recommendation
No
Recommendation
Suggest
20
Pain assessments should be based on objective signs such as tachypnea,
tachycardia, diaphoresis, accessory muscle use, nasal flaring, grimacing, rigidity,
wincing, shutting of eyes, clenching of fists, verbalization and moaning.
A heart rate above 100 bpm should be interpreted as pain.
A respiratory rate above 35 bpm should be interpreted as pain.
A respiratory rate above 20 bpm should be interpreted as pain.
Pain should be assessed by an interprofessional team of raters.
SDMs/family members should be involved in decisions about whether the patient
is in pain.
Assessment of agitation requires a standardized assessment scale.
The agitation assessment scale of choice during WDLS should be validated in ICU
patients (e.g. SAS, RASS).
Assessment of agitation during WDLS requires Bispectral EEG.
Assessment of respiratory distress requires a standardized assessment tool.
The respiratory distress assessment tool of choice is the respiratory distress
observation scale.
A respiratory rate >35 should be interpreted as respiratory distress.
A respiratory rate >20 should be interpreted as respiratory distress.
A respiratory rate rising >50% above baseline should be interpreted as respiratory
distress.
Assessment of respiratory distress should be based on tachypnea, tachycardia, a
fearful facial expression, accessory muscle use, paradoxical breathing and nasal
flaring.
Respiratory distress should be assessed by an interprofessional team of raters.
SDMs/family members should be involved in decisions about whether the patient
is in respiratory distress.
When appropriate, patients should be assessed for delirium during WDLS using a
standardized, validated assessment tool (e.g. CAM-ICU, ICDSC).
Whenever treatment is given, the rationale should be documented using the
recommended criteria.
12,20
1,8,12,20,27
20
20
29
30
31
32
1,8,12,20,27
20
29
5,27
Section #3: Pharmaceutical Management of Distress
Original Statement
Level of Evidence
References
The goal of pharmaceutical treatment during WDLS is to prevent symptoms
(i.e. comfort medications should be given when discomfort is anticipated but
not yet apparent).
The goal of pharmaceutical treatment during WDLS is to treat symptoms (i.e.
comfort medications should be given only when discomfort is apparent).
Paralytic medications should be discontinued and their effects reversed
enough so that the team can appreciate signs of distress from the patient prior
to WDLS (Train of four at least 3/4).
There are some exceptional circumstances when you may want to WDLS
before paralytic medications have worn off. For example, if imminent death is
expected and a delay in WDLS would prolong suffering for no clear benefit (e.g.
status epilepticus, traumatic brain injury).
If the patient is already comfortable on a stable dose of opioid and sedative,
these should be continued during WDLS.
If the patient is already comfortable on a stable dose of sedative it should be
continued at that dose.
Opioids and sedatives could be used in combination for symptom management
during WDLS if the current symptom management regime is insufficient.
Morphine is the opioid of choice for initial therapy of an opioid-naïve patient
to treat pain and/or dyspnea during WDLS.
Benzodiazepines should only be used for sedation during WDLS once pain is
effectively treated.
Sedatives such as barbiturates or propofol should be used as second-line for
sedation during WDLS, when benzodiazepines are ineffective, or in exceptional
circumstances.
Anticholinergic medications (e.g. butylscopolamine 20mg IV) should be given
pre-extubation to prevent upper airway secretions during WDLS.
Opioids and sedatives should be titrated to symptoms with no specified dose
limit during WDLS.
Furosemide should be given 6h pre-extubation if the patient appears
intravascularly overloaded.
Methylprednisolone 100mg or another corticosteroid should be given 6h preextubation to prevent post-extubation stridor in the conscious patient.
Racemic epinephrine should be used to treat post-extubation stridor in the
conscious patient.
Anti-nausea medications should be ordered PRN with opioids.
Suggest
10,11,14,21,27,33,3
Pain or respiratory distress should be treated with an IV bolus dose of an
opioid followed by a continuous infusion.
In symptomatic adult patients who are opioid naïve a usual starting bolus dose
of IV morphine is 2mg (or equianalgesic dose of another opioid), titrated to
effect. These doses should be adjusted up or down, based on considerations of
size, age, and organ dysfunction.
In opioid naïve patients who remain symptomatic after receiving an infusion of
morphine, it is reasonable to give a bolus of 2x the hourly infusion dose. If a
patient receives 2 bolus doses in an hour, it is reasonable to double the
infusion rate.
Intravenous morphine/hydromorphone bolus doses should be ordered q15
mins prn.
4
Suggest
6,10,11,14,16,17,27
,29
Suggest
1,6,9,11,27
No
Recommendation
5
No
Recommendation
No
Recommendation
Suggest
8
Suggest
3,6,7,11,14,16,21,3
8
11,14,27,35,36
7
No
Recommendation
Suggest
-
No
Recommendation
Recommend
11
No
Recommendation
No
Recommendation
No
Recommendation
No
Recommendation
Suggest
11
Suggest
1,3,7,9,11
Suggest
7,9,16
Suggest
7,8
9,21
4,11,16,27
11
38
3
7-10,16
Intravenous fentanyl bolus doses should be ordered q5 mins prn.
Suggest
3,6
For a sedative-naïve patient, symptoms should be treated with an IV bolus
dose of sedative followed by an infusion.
In symptomatic adults who are benzodiazepine naïve it is reasonable to give a
2mg IV bolus of midazolam followed by an infusion of 1mg/hour. These doses
should be adjusted up or down, based on considerations of size, age, and
organ dysfunction.
In adults who become symptomatic while receiving a stable infusion of
midazolam, it is reasonable to give a bolus of 1-2x the hourly infusion dose. If a
patient receives 2 bolus doses in an hour, it is reasonable to double the
infusion rate.
Intravenous midazolam bolus doses can be ordered q5min prn for someone on
a stable infusion of midazolam.
Propofol is an alternative sedative to midazolam during WDLS for patients who
are already comfortable on a stable infusion of propofol.
Physicians who are familiar with using propofol as a sedative may use propofol
as an alternative to midazolam for sedative-naïve patients during WDLS.
Suggest
3,6-9
Suggest
3,6,8,9
No
Recommendation
-
Suggest
3,6
Suggest
3,6,14,39,40
Suggest
3,6,14
Section #4: Withdrawal of Life-Sustaining Therapies
Original Statement
Level of Evidence
References
All non-comfort medications should be discontinued.
Suggest
3,5,6,8-10
All blood product transfusions should be discontinued.
Suggest
3,5,6,8-10,41
Hemodialysis should be discontinued.
Suggest
3,5,6,8-10,41
Vasopressors should be discontinued.
Suggest
3,5,6,8-10
Total parenteral nutrition should be discontinued.
Suggest
3,5,6,8-10
Antibiotics should be discontinued.
Suggest
3,5,6,8-10
IV fluids should be discontinued.
Suggest
6,7,9,10,16,23
Tube feeding should be discontinued.
Suggest
1,6,7,9,10,16,23,42
All bloodwork should be discontinued.
Suggest
3,5,6,8-10
All treatments and monitoring that are not helping achieve comfort should be
discontinued.
Vasopressors and inotropes should be discontinued first, followed by
mechanical ventilation and any artificial airway in a stepwise manner.
Life-sustaining therapies should be withdrawn in a stepwise manner, ensuring
alleviation of any dyspnea, anxiety/agitation and pain at each step.
Supplementary oxygen should not be provided unless it is needed for comfort.
Suggest
3,5,6,8-10
No
Recommendation
Suggest
42
No
Recommendation
No
Recommendation
Suggest
45
No
Recommendation
Suggest
-
Suggest
43
No
Recommendation
-
Suggest
1,8
No
Recommendation
No
Recommendation
-
The sequence and process of withdrawal of mechanical ventilation must be
individualized with comfort as the paramount goal.
Mechanical ventilation should be withdrawn as quickly as possible, with the
speed of withdrawal determined by the time it takes to achieve comfort at
each step.
The speed of WDLS must be individualized for each patient.
In most cases of WDLS, we should aim to extubate patients to room air.
When mechanical ventilation is withdrawn and death is anticipated, extubation
is preferable to leaving the patient intubated, with or without a T-piece or low
level PS/CPAP.
When withdrawing mechanical ventilation, it is acceptable to extubate the
patient to room air or supplemental oxygen, or to leave the patient intubated
with CPAP or a T-piece.
Withdrawal of mechanical ventilation and life-sustaining treatments protocols
should be developed and utilized in each ICU.
Patients should not be routinely extubated to non-invasive mechanical
ventilation.
In a pharmacologically paralyzed patient, CPAP, T-piece and extubation are not
permissible.
42-44
5-7,38
43
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