Intensive care limitations and end-of-life care framework

LIMITATIONS AND END-OF-LIFE CARE FRAMEWORK
Please complete this form if the decision to limit therapy is made and file at the front of the medical notes. At this
time, it is also appropriate to consider the patient’s resuscitation status.
Patient Name________________________ Hospital Number_______________________
DOB_______________________________ Sex__________________________________
If decision is made to actively withdraw care, please move on and complete pages 2-5.
LIMITATION OF VENTILATION
 For intubation or reintubation
 For ventilatory escalation or reventilation
 Have limits been placed for respiratory support? If so, please complete table below
CMV
FiO2 RR PC/Vt PEEP
SIMV/BiLEVEL
FiO2 RR PC/Vt Ps/high/ASB PEEP/Plow
PS/CPAP
ASB/ CPAP
FiO2 RR Ps/high/ASB PEEP/Plow
N/A
 For non-invasive ventilation, please specify ____________________________________________
Any other limits, please specify: ___________________________________________________________________
LIMITATION OF INOTROPE/VASOPRESSOR SUPPORT
Please state drug and limits for infusion
Name of drug Infusion limits (mcg/kg/min, specify if different)
Any other drug, please specify and include limits: ____________________________________________________
RENAL SUPPORT
 Is renal replacement therapy appropriate?
 Is diuretic therapy appropriate for fluid balance?
 Is medical/pharmacological treatment for hyperkalaemia and/or pulmonary oedema appropriate?
AUTHORISATION OF TREATMENT LIMITATIONS
Decision made by Dr __________________________________ Grade _________________________________
Signature __________________________________________ Date __________________________________
Discussed with family and consultant; if so please state who ____________________________________________
Page 1 of 8 Sherren & Yoganathan 2009

REVERSAL OF DECISION (CROSS THROUGH PREVIOUS SECTION AND COMPLETE
BELOW)
Decision made by Dr __________________________________ Grade _________________________________
Signature __________________________________________ Date __________________________________
Discussed with family and consultant; if so please state who ____________________________________________
Reason for reversal ____________________________________________________________________________
ADDITIONAL COMMENTS
_____________________________________________________________________________________________
______________________________________________________________________________________________

END-OF-LIFE CARE FRAMEWORK
Once the decision has been made to withdraw therapy, please use the framework below. The framework is designed
as a prescription order; tick the boxes and prescriptions applicable to your withdrawal plan. Please note there will be
instances when parts of this framework will not be appropriate / applicable. Please refer to the exclusion criteria at the
end of this framework for details on who should NOT be included.
Patient Name ________________________ Hospital Number _______________________
DOB _______________________________ Sex _________________________________
BASICS
 Documentation in notes regarding withdrawal and reasons why
Decision discussed with Family
Intensive Care Consultant
Named Consultant



 Do not attempt resuscitation (DNAR) order signed
 Remove all non-essential monitoring (e.g. CO monitoring / Manuel BP / SPO2 etc)
 Discontinue non-essential observations (continue any required for pain assessment)
 Discontinue all non-essential medications (including LMWH / Antibiotics / Gastric protection etc)
 Discontinue renal replacement therapy
 Ensure effects of neuromuscular blocking / paralytic agents (if used) no longer persist
 Organ donation discussed with family / transplant coordinator and found not to be appropriate
NB - If brain stem death is confirmed, please refer to exclusion criteria at end of framework
CVS
 Continue ECG / invasive BP (for pain assessment)
 Discontinue inotropes once appropriately sedated and comfortable
 Continue / Start intravenous fluids if not enterally/parenterally fed already. Once
enteral/parenteral feed bag finished change over to intravenous fluid maintenance.

SEDATION
Select one of the below if required:
 Midazolam infusion
• Continue current rate if comfortable or start at specified dose ____ mg/Hr
• Bolus ____ mg if there are signs of distress
• +increase infusion rate by 25% every 15 mins if required
 Propofol infusion
• Continue current rate if comfortable or start at specified dose ____ mg/Hr
• +increase infusion rate by 25%, every 15 mins if required
 Other Sedatives at specified dose ____________________________________________________
_______________________________________________________________________________
ANALGESIA
Select one of the below if required:
 Morphine infusion
• Continue at current rate if comfortable or start at specified dose ____ mg/Hr
 Fentanyl Infusion
• Continue current rate if comfortable or start at specified dose ____ mcg/Hr
• Bolus ____ mcg if there are signs of distress
 Alfentanil Infusion
• Bolus ____ mcg if there are signs of distress
 Remifentanil infusion
• +increase infusion rate by 25%, every 15 mins if required.
NB. - Primary importance is to ensure comfort of patient, concerns to respiratory depression is secondary.
RESPIRATORY
 Switch off Alarms
 Document initial ventilatory parameters
CMV
FiO2 RR PC/Vt PEEP

SIMV/BiLEVEL
PS/CPAP
ASB/ CPAP
N/A
(11  Document new ventilatory parameters to be achieved. Gradually reduce each parameter in turn
over 10 minutes, titrating sedation/analgesia as required
CMV
FiO2 RR PC/Vt PEEP
SIMV/BiLEVEL
PS/CPAP
ASB/ CPAP
N/A
(11  Once comfortable on new ventilatory parameters, select one of the following:
 continue with current airway support (e.g. COETT) and ventilation
 extubate to air
 place on a T-piece / Swedish nose

ADDITIONAL PRESCRIPTIONS (Hyoscine, anti-emetics etc)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
OTHER COMMENTS
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
DOCTOR
First Name: Last Name: __
Grade: Date: __
SIGNATURE:
CONSULTANT
First Name: Last Name: __
Date:
SIGNATURE:
NURSE
First Name: _________________________ Last Name: ______________________________
Date: ______________________________
SIGNATURE: ___________________
Exclusion Criteria
The following scenarios / situations should be excluded from the Withdrawal of Care Framework (unless
otherwise specified by the Consultant in charge of care):
1. Patient is confirmed as brainstem dead
2. Patient is awaiting organ donation or a decision has yet to be made regarding this

3. Patient is undergoing CPR
4. Patient has not been discussed with / reviewed by a consultant
5. Patient is under 16
APPENDIX
Withholding and withdrawing life-prolonging treatments: Good practice in decision-
making (Good medical practice, 2006)
1. Doctors have a duty to protect the life and further the health of patients. A number of legal judgements on withholding and withdrawing
treatment have shown that the courts do not consider that protecting life (the 'sanctity of life' principle) always takes precedence over other
considerations. The case law identifies some circumstances where withholding or withdrawing a life-prolonging treatment would be lawful,
and establishes the following principles (see endnotes for case references):
• An act where the doctor's primary intention i is to bring about a patient's death would be unlawful ii.
• Withholding or withdrawing treatment is regarded in law as an 'omission' not an 'act'.
• A competent adult patient may decide to refuse treatment even where refusal may result in harm to themselves or in their own
death iii. This right applies equally to pregnant women as to other patients, and includes the right to refuse treatment where the
treatment is intended to benefit the unborn child iv. Doctors are bound to respect a competent refusal of treatment and, where
they have an objection to the decision, they have a duty to find another doctor who will carry out the patient's wishes v.
• Life prolonging treatment may lawfully be withheld or withdrawn from incompetent patients when commencing or continuing
treatment is not in their best interests vi.
• There is no obligation to give treatment that is futile and burdensome vii.
• Where an adult patient has become incompetent, a refusal of treatment made when the patient was competent must be
respected, provided it is clearly applicable to the present circumstances and there is no reason to believe that the patient had
changed his/her mind viii.
• For children or adults who lack capacity to decide, in reaching a view on whether a particular treatment would be more
burdensome than beneficial, assessments of the likely quality of life for the patient with or without the particular treatment may be
one of the appropriate considerations ix.
• In the case of patients in a permanent vegetative state (PVS), artificial nutrition and hydration constitute medical treatment and
may be lawfully withdrawn in certain circumstances x28. However, in practice, a court declaration should be obtained xi.
• Final responsibility rests with the doctor to decide what treatments are clinically indicated and should be provided to the patient,
subject to a competent patient's consent or, in the case of an incompetent patient, any known views of that patient prior to
becoming incapacitated and taking account of the views offered by those close to the patient xii.
2. Case law also suggests that:
• Where a patient's capacity to consent to or refuse a treatment remains in doubt after appropriate steps have been taken to assess
their capacity, or where differences of opinion about a patient's best interests cannot be resolved satisfactorily, legal advice should
be sought about applying to the courts for a ruling.
• When the Court is asked to reach a view on whether it is in an incompetent patient's best interests to withhold or withdraw a
treatment, it will have regard to whether what is proposed is in accordance with a responsible body of medical opinion. But the
Court will determine for itself whether treatment or non-treatment is in the patient's best interests xiii.
3. It is also important to note that the Human Rights Act 1998 may have implications for this area of medical decision making by incorporating
into English law the European Convention on Human Rights. Notably under that Convention, Article 2 requires that a person's right to life be
protected by law; Article 3 prohibits inhuman and degrading treatment; and Article 8 requires respect for private and family life. As relevant
case law emerges, the exact scope of these rights and how they may be balanced against one another will become clearer. At present the
case law confirms that the existing common law principles are consistent with the European Convention on Human Rights xiv. It is also clear

that doctors' decisions are likely to be subject to greater scrutiny and the decision making process will need to be open, transparent and
justifiable.
4. Other legislative changes affecting patients' rights, such as provisions in the Adults with Incapacity (Scotland) Act 2000, mean that the
legal position in Scotland, Northern Ireland, England and Wales could diverge significantly in future years. Such changes reinforce the
importance of doctors obtaining up to date advice and guidance on the legal as well as clinical issues affecting their practice in this area.
i R v Cox (1992) 12 BMLR 38.
ii For a very rare exception in the case of conjoined twins see Re: A (Children) (Conjoined twins: surgical separation) [2000] 4 All ER 961.
iii Airedale NHS Trust v Bland [1993] 1 All ER 821 at page 860 per Lord Keith and page 866 per Lord Goff. Also Re JT (Adult: Refusal of
Medical Treatment) [1998] 1 FLR 48 and Re AK (Medical Treatment: Consent) [2001] 1 FLR 129.
iv St George's Healthcare Trust v S (No 2). R v Louise Collins & Others, Ex Parte S (No 2) [1993] 3 WLR 936.
v Re Ms B v a NHS Hospital Trust [2002] EWHC 429 (Fam).
vi Airedale NHS Trust v Bland [1993] 1 All ER 821.
vii Re J (A Minor) (Wardship: Medical Treatment) [1990] 3 All ER 930.
viii Airedale NHS Trust v Bland [1993] 1 All ER 821 at page 860 per Lord Keith and page 866 per Lord Goff. Also Re T (Adult: Refusal of
Treatment) [1992] 4 All ER 349 and Re AK (Medical Treatment: Consent) [2001] 1 FLR 129.
ix Re B [1981] 1 WLR 421; Re C (A Minor) [1989] All ER 782; Re J (A Minor) (Wardship: Medical Treatment) [1990] 3 All ER 930; Re R
(Adult: Medical Treatment) [1996] 2 FLR 99.
x Airedale NHS Trust v Bland [1993] 1 All ER 821; Law Hospital NHS Trust v Lord Advocate 1996 SLT 848.
xi Airedale NHS Trust v Bland [1993] 1 All ER 821; Law Hospital NHS Trust v Lord Advocate 1996 SLT 848. Also refer to Practice Note
(Official Solicitor: Declaratory Proceedings: Medical and Welfare Decisions for Adults Who Lack Capacity) [2001] 2 FLR.
xii Re J (A Minor) (Child in Care: Medical Treatment) [1992] 2 All ER 614; and Re G (Persistent Vegetative State) [1995] 2 FCR 46.
xiii Re A (Male Sterilisation) [2000] FCR 193; and Re S (Adult: Sterilisation) [2000] 2 FLR 389.
xiv A National Health Trust v D (2000) 55 BMLR 19; NHS Trust A v M and NHS Trust B v H (2000) 58 BMLR 87.
Withholding and withdrawing life-prolonging medical treatment. Guidance for decision-
making (British Medical Association, 1999)
Where the patient’s imminent death is believed to be inevitable, artificial nutrition and hydration may be withheld or withdrawn if it not
considered to be a benefit to the patient.
In these final stages, active treatment and provision of artificial nutrition and hydration may become unnecessarily intrusive and merely
prolong the dying process rather than offering a benefit to the patient. Oral/intravenous hydration can be considered if it is thought to be
necessary for the patient’s comfort.

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