Withdrawal of Life Sustaining Medical Treatment Plan

• Introduction
• Using the ‘Withdrawal Plan’ document
• Where/when should WOLSTP be used?
• Organ Donation
• Care of the dying person
• Withdrawal algorithm

Introduction

Invasive organ support does not always lead to clinical improvement or a patient’s recovery from critical illness. On occasions the multidisciplinary team caring for a patient in critical care may decide, in collaboration with the patient (where possible) and the patient’s family  that continuing invasive organ support is no longer in the patient’s best interests.

The withdrawal of life sustaining treatment is arguably the highest impact intervention within critical care. As such, it is vital that withdrawal decisions are communicated clearly and the action of withdrawal always carried out for the correct patient at the correct time.

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Using the ‘Withdrawal Plan’ document

The ‘Withdrawal of life sustaining medical treatment plan’ (WOLSTP) has two sections.

Section 1  - the ‘withdrawal prescription’ - records who has made the withdrawal decision and what aspects of life sustaining treatment are going to be withdrawn.  All withdrawal decisions should be made by a consultant. Section 1 may be completed by a registrar (St3 – 7) in consultation with a consultant. If a registrar completes section 1, they should record the name of the consultant with whom the withdrawal decision has been discussed on the form.

After a collaborative decision has been made to withdraw life sustaining treatment, there may be several pre-withdrawal requests to be honoured/arranged before treatment is actually withdrawn. Often patients and their families request a period of time for other family members to attend. Patients may wish for a member of the chaplaincy team to visit. The patient’s wishes around organ donation also need to be explored. Any actions or events that are requested to occur prior to withdrawal of treatment should be recorded at the end of section 1.
 
Section 2 - the ‘pre-withdrawal pause’ - should be completed immediately prior to the withdrawal of treatment. The action of withdrawal may occur many hours after the decision to withdraw treatment was made. Occasionally there may be a change of medical and/or nursing staff between the decision to withdraw and the action of withdrawing. The ‘pre-withdrawal pause’ is therefore intended as a safety check, ensuring that withdrawal occurs for the correct patient at the correct time. The pause consists of a doctor, a senior nurse and the patient’s named nurse gathering at the patient’s bedside immediately prior to withdrawal of treatment. If the patient or their family have consented to organ donation then the specialist nurse for organ donation (SNOD) should also be present. These three or four individuals then collaboratively run through the checklist to ensure all prerequisites to withdrawal have been fulfilled. The group conducting the pause should then sign Section 2 and record the date and time of withdrawal.

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Where/when should WOLSTP be used?

The ‘Withdrawal of life sustaining medical treatment plan’ is intended for use in critical care or other clinical areas where life sustaining treatment is being withdrawn – for example the emergency department. It should be used to record all life sustaining treatment withdrawal decisions. It is not intended to be used on general wards or for all dying patients.

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Organ Donation

A significant proportion of the population wish to donate their organs after death for the purposes of transplantation and around a third of the population have recorded their donation decision on the Organ Donor Register (ODR). It is best practice to explore the donation wishes of every patient in whom a decision has been made to withdrawal life sustaining treatment. All patients should be referred to the specialist nurse for organ donation (SNOD). If a ITUs embedded SNOD is unavailable then please use the on call pager number: 03000 20 30 40. A SNOD will be able to check a patient’s ODR status and confirm whether they are eligible as a potential donor. They will also be available to attend the ward to explore a patient’s wishes with their family. Should a patient and/or their family consent to organ donation, a SNOD will accompany the patient and support their family throughout the withdrawal and donation pathway.

NICE guideline 135 sets out in detail the responsibilities of the critical care team towards organ donation. A summary of the guidance can be found on the reverse of the ‘withdrawal plan’ document.

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Care of the dying person

Medical and nursing staff are encouraged to consider using the LTHT’s ‘Care of the dying person (adult) care plan’ (LTH0117) when a patient’s  life expectancy after withdrawal is anticipated to be measured in hours to days. Many patients in critical care are expected to die within a very short time after withdrawal of invasive support. In these circumstances, LTH0117 may be deemed unnecessary and so with this in mind WOLSTP summarises the 5 priorities of care from One chance to get it right (Leadership Alliance for the Care of Dying Person) and prompts staff to prescribe appropriate medications for pain, agitation, nausea, secretions and dyspnoea. In addition to the treatments/devices listed in section 1, consideration should also be given as to the benefits/burdens of removing/leaving in peripheral cannula and/or urinary catheters.

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Withdrawal algorithm

The following algorithm summarises the care pathway for patients undergoing withdrawal of life sustaining medical treatment.

WITHDRAWAL OF SUPPORT – ALGORITHM

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