Electronic Supplemental Material Appendix #2- Original Statements (Round 1) and Strength of Evidence.

Section #1- Preparation for Withdrawal of Life SupportOriginal Statement Level of Evidence ReferencesA patient-specific interprofessional care plan for the process of WDLS should be outlined.

No Recommendation

-

An experienced physician, bedside nurse and respiratory therapist must be available to respond quickly to significant signs of distress at the time of extubation.

Suggest 1-4

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.

No Recommendation

-

Whenever possible, patients should be moved to a private room or curtains drawn.

Suggest 5-7

Visitation should be liberalized. Suggest 5-7

Whenever possible monitors should be turned off in the room and shifted to another screen.

Suggest 3,5,6,8-10

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.

No Recommendation

-

Physicians must communicate with bedside nurse regarding the patient’s comfort as required and to assist the interprofessional team in providing palliative care.

Suggest 1,3,9

Physicians must be readily available to assess and treat if new symptoms arise after the team deems the patient comfortable.

Suggest 1,3,9

The interprofessional team should be educated on acute bereavement support.

Suggest 6,9-11

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.

Suggest 4,11,12

A debriefing session should occur after a particularly challenging WDLS. 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.

No Recommendation

-

Members of the interprofessional team should be involved in discussions with the patient and SDM/family regarding what to expect during WDLS.

Suggest 11,13,14

The process of WDLS and the role of each team member should be outlined to patients (when appropriate) and SDMs/families.

Suggest 15

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.

Suggest 2,3,7,11,14

SDMs/families should be informed that time to death is variable and cannot be predicted.

Suggest 2,7,11,14

SDMs/families should be educated on physical signs and symptoms they may witness.

Suggest 2,3,7,11,14

SDMs/families should be educated on how pain and any other signs of distress will be assessed and treated. [RECOMMEND]

Suggest 2,3,7,11,14

All members of the interprofessional team play an important role in supporting patients and SDMs/families at the bedside during WDLS.

No Recommendation

-

Physicians should return to the bedside at regular intervals to ensure No -

emotional and psychological support of SDMs/families if appropriate. RecommendationSDMs/families should be allowed to be present during WDLS. Suggest 5-7

SDMs/families should be allowed to participate in the care of patients during WDLS.

No Recommendation

10

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.

Suggest 3,7,9

A private quiet room should be made available to SDMs/families. No Recommendation

-

SDMs/families should be allowed to stay overnight in the ICU. No Recommendation

5

Whenever possible, religious and cultural rituals should be facilitated. Suggest 1-3,7,9-11,14-23

Whenever possible WDLS should incorporate ways to respect honour and/or celebrate the uniqueness of the person who is the patient.

Suggest 1-3,7,9-11,14-23

Patients and SDMs/families may be given an opportunity to contact their own clergy or spiritual support.

No Recommendation

1

Hospital spiritual care and/ or social work should be consulted and invited to be present during discussions of WDLS process.

Suggest 1,3,5-7,10,11,16-

18,24

Young children of adult patients should receive particular attention and support from the interprofessional team.

No Recommendation

-

SDMs/families should be educated about the grieving process. Suggest 6,9,11

SDMs/families should be offered acute grief support. Suggest 6,9

SDMs/families should be offered a referral to community bereavement services.

Suggest 6,9

SDMs/families may be offered a future debriefing session with the physician and/or interprofessional team.

No Recommendation

-

SDMs/families should be sent a letter of condolence including bereavement support information.

No Recommendation

25

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.

No Recommendation

-

Critical Care units should develop resources outlining available resources for grief and bereavement support including support groups in their area.

No Recommendation

-

Section #2: Assessment of DistressOriginal Statement Level of Evidence ReferencesPain 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.

No Recommendation

6

The standardized pain scoring system of choice is the Critical Care Pain Observation Tool.

Suggest 12,20

The standardized pain scoring system of choice in pediatrics is the COMFORT scale. No Recommendation

-

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.

Suggest 1,8,12,20,27

A heart rate above 100 bpm should be interpreted as pain. No Recommendation

28

A respiratory rate above 35 bpm should be interpreted as pain. No Recommendation

-

A respiratory rate above 20 bpm should be interpreted as pain. No Recommendation

-

Pain should be assessed by an interprofessional team of raters. No Recommendation

20

SDMs/family members should be involved in decisions about whether the patient is in pain.

No Recommendation

20

Assessment of agitation requires a standardized assessment scale. No Recommendation

-

The agitation assessment scale of choice during WDLS should be validated in ICU patients (e.g. SAS, RASS).

No recommendation

29

Assessment of agitation during WDLS requires Bispectral EEG. No Recommendation

30

Assessment of respiratory distress requires a standardized assessment tool. No Recommendation

31

The respiratory distress assessment tool of choice is the respiratory distress observation scale.

No Recommendation

-

A respiratory rate >35 should be interpreted as respiratory distress. No Recommendation

-

A respiratory rate >20 should be interpreted as respiratory distress. No Recommendation

-

A respiratory rate rising >50% above baseline should be interpreted as respiratory distress.

No Recommendation

32

Assessment of respiratory distress should be based on tachypnea, tachycardia, a fearful facial expression, accessory muscle use, paradoxical breathing and nasal flaring.

Suggest 1,8,12,20,27

Respiratory distress should be assessed by an interprofessional team of raters. No Recommendation

20

SDMs/family members should be involved in decisions about whether the patient is in respiratory distress.

No Recommendation

20

When appropriate, patients should be assessed for delirium during WDLS using a standardized, validated assessment tool (e.g. CAM-ICU, ICDSC).

No Recommendation

29

Whenever treatment is given, the rationale should be documented using the recommended criteria.

Suggest 5,27

Section #3: Pharmaceutical Management of DistressOriginal Statement Level of Evidence ReferencesThe 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).

Suggest 10,11,14,21,27,33,34

The goal of pharmaceutical treatment during WDLS is to treat symptoms (i.e. comfort medications should be given only when discomfort is apparent).

Suggest6,10,11,14,16,17,27,2

9

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).

Suggest 1,6,9,11,27

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).

No Recommendation

5

If the patient is already comfortable on a stable dose of opioid and sedative, these should be continued during WDLS.

No Recommendation

8

If the patient is already comfortable on a stable dose of sedative it should be continued at that dose.

No Recommendation

8

Opioids and sedatives could be used in combination for symptom management during WDLS if the current symptom management regime is insufficient.

Suggest 11,14,27,35,36

Morphine is the opioid of choice for initial therapy of an opioid-naïve patient to treat pain and/or dyspnea during WDLS.

Suggest 3,6,7,11,14,16,21,37

Benzodiazepines should only be used for sedation during WDLS once pain is effectively treated.

No Recommendation

-

Sedatives such as barbiturates or propofol should be used as second-line for sedation during WDLS, when benzodiazepines are ineffective, or in exceptional circumstances.

Suggest 9,21

Anticholinergic medications (e.g. butylscopolamine 20mg IV) should be given pre-extubation to prevent upper airway secretions during WDLS.

No Recommendation

11

Opioids and sedatives should be titrated to symptoms with no specified dose limit during WDLS.

Recommend 4,11,16,27

Furosemide should be given 6h pre-extubation if the patient appears intravascularly overloaded.

No Recommendation

11

Methylprednisolone 100mg or another corticosteroid should be given 6h pre-extubation to prevent post-extubation stridor in the conscious patient.

No Recommendation

11

Racemic epinephrine should be used to treat post-extubation stridor in the conscious patient.

No Recommendation

38

Anti-nausea medications should be ordered PRN with opioids. No Recommendation

3

Pain or respiratory distress should be treated with an IV bolus dose of an opioid followed by a continuous infusion.

Suggest 7-10,16

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.

Suggest 1,3,7,9,11

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.

Suggest 7,9,16

Intravenous morphine/hydromorphone bolus doses should be ordered q15 Suggest 7,8

mins prn.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.

Suggest 3,6-9

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.

Suggest 3,6,8,9

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.

No Recommendation

-

Intravenous midazolam bolus doses can be ordered q5min prn for someone on a stable infusion of midazolam.

Suggest 3,6

Propofol is an alternative sedative to midazolam during WDLS for patients who are already comfortable on a stable infusion of propofol.

Suggest 3,6,14,39,40

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 3,6,14

Section #4: Withdrawal of Life-Sustaining TherapiesOriginal Statement Level of Evidence ReferencesAll 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.

Suggest 3,5,6,8-10

Vasopressors and inotropes should be discontinued first, followed by mechanical ventilation and any artificial airway in a stepwise manner.

No Recommendation

42

Life-sustaining therapies should be withdrawn in a stepwise manner, ensuring alleviation of any dyspnea, anxiety/agitation and pain at each step.

Suggest 42-44

Supplementary oxygen should not be provided unless it is needed for comfort. No Recommendation

45

The sequence and process of withdrawal of mechanical ventilation must be individualized with comfort as the paramount goal.

No Recommendation

-

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.

Suggest 5-7,38

The speed of WDLS must be individualized for each patient. No Recommendation

-

In most cases of WDLS, we should aim to extubate patients to room air. Suggest 43

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.

Suggest 43

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.

No Recommendation

-

Withdrawal of mechanical ventilation and life-sustaining treatments protocols should be developed and utilized in each ICU.

Suggest 1,8

Patients should not be routinely extubated to non-invasive mechanical ventilation.

No Recommendation

-

In a pharmacologically paralyzed patient, CPAP, T-piece and extubation are not permissible.

No Recommendation

-

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