title: Guidelines for the withdrawal of life-sustaining measures.
abstract: BACKGROUND
  Withdrawal of life-sustaining measures is a common event in the intensive care unit yet it involves a complex balance of medical, legal and ethical considerations. Very few healthcare providers have been specifically trained to withdraw life-sustaining measures, and no comprehensive guidelines exist to help ensure clinicians deliver the highest quality of care to patients and families. Hence, we sought to develop guidelines for the process of withdrawing life-sustaining measures in the clinical setting.
  
  
  METHODS
  We convened an interdisciplinary group of ICU care providers from the Canadian Critical Care Society and the Canadian Association of Critical Care Nurses, and used a modified Delphi process to answer key clinical and ethical questions identified in the literature.
  
  
  RESULTS
  A total of 39 experienced clinicians completed the initial workshop, and 36 were involved in the subsequent Delphi rounds. The group developed a series of guidelines to address (1) preparing for withdrawal of life-sustaining measures; (2) assessment of distress; (3) pharmaceutical management of distress; and (4) discontinuation of life-sustaining measures and monitoring. The group achieved consensus on all aspects of the guidelines after the third Delphi round.
  
  
  CONCLUSIONS
  We present these guidelines to help physicians provide high-quality end of life (EOL) care in the ICU. Future studies should address their effectiveness from both critical care team and family perspectives.
authors.affiliation: Divisions of Critical Care Medicine and Palliative Care, University of Toronto, Toronto, Canada. james.downar@utoronto.ca.
authors.forename: James
authors.initials: J
authors.lastname: Downar
authors.affiliation: Rouge Valley Health System, Toronto, Canada.
authors.forename: Jesse W
authors.initials: JW
authors.lastname: Delaney
authors.affiliation: Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
authors.forename: Laura
authors.initials: L
authors.lastname: Hawryluck
authors.affiliation: Faculty of Medicine, Memorial University of Newfoundland, St. John's, Canada.
authors.forename: Lisa
authors.initials: L
authors.lastname: Kenny
mesh_terms: D002170:Canada; D003657:Decision Making; D003697:Delphi Technique; D005066:Euthanasia, Passive; D005190:Family / Q000523:psychology; D006117:Grief; D006801:Humans; D007400:Interprofessional Relations; D008020:Life Support Care / Q000592:standards*; D010147:Pain Measurement / Q000379:methods; D010166:Palliative Care / Q000592:standards; D000070659:Patient Comfort / Q000379:methods; D011595:Psychomotor Agitation; D012131:Respiratory Insufficiency; D013727:Terminal Care / Q000592:standards*
keywords: Consensus; Critical care; Delphi technique; Life support care; Palliative care; Standards; Terminal care