PLACE LABEL HERE

WITHDRAWAL OF LIFE SUSTAINING TREATMENT

ORDERS

Reference Page

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 NOTbe 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:Immediate Extubation: to room air OR  O2 per nasal cannula for comfort

Terminal Wean

9.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 motoractivity 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 1-4mgIVq hour prn

OR Fentanyl 25-100mcg IV q hour prn

13. Anxiety or Agitation:

Ativan (lorazepam)0.5-2mg IV q 4 hrsprn

OR Versed(midazolam) 2-5mg 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)

Principles for Withdrawing Life Sustaining Treatment:

  1. Withdrawal of life sustaining treatment is a medical procedure that requires qualified physician participation.
  1. Withholding treatment is morally and legally equivalent to withdrawing treatment.
  1. 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.
  1. Any treatment can be withdrawn including nutrition, fluids, antibiotics, blood products, and dialysis.
  1. 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.
  1. 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.
  1. 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 1 of 2

PLACE LABEL HERE

WITHDRAWAL OF LIFE SUSTAINING TREATMENT

ORDERS

Reference Page

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/hrprn to control or prevent pain/respiratorydistress

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 1mg q 30 minprn 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 IVq 4 hrsprn

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)

Onesignature 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.

Threephysician 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______

FORM 4-3125 REV. 09/2013 REFERENCE PAGE Page 1 of 2