A five-step protocol for withholding and withdrawing of life support in an emergency department: an observational study

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The objective of the study was to describe a five-step protocol for withholding and withdrawing of life support (WH/WDLS) in an emergency department (ED) for terminally ill patients.

Design and setting

An observational study was conducted in ED of a general hospital.


A total of 98 patients were admitted over a 1-year period.


The healthcare team chose a pattern of treatment limitation on the basis of a five-step protocol for every patient, which comprised five groups: group 1: there was no limitation of care, group 2: do not resuscitate order was followed, group 3: administration of therapies without treating an acute organ failure, group 4: active withdrawal of all therapies except mechanical ventilation and group 5: active withdrawal of mechanical ventilation. All the patients received comfort care. The opinions of the patients and their families were collected.

Measurements and results

Ninety-eight patients were included in the study (1.5% of admissions). Mean age was 82±13 years. An acute organ failure was observed at admission in 80 patients. Severe chronic disease was noted in 93 patients. Among the 98 patients, there were 14 patients in group 2, 65 in group 3, six in group 4 and 13 in group 5. The time interval between admission and WH/WDLS decision was 117±77 min and ED stay was 239±136 min. The outcome was death in ED (n=21), admission to a medical ward (n=71) or an intensive care unit (n=six). On day 30, 16 patients were still alive.


This five-step protocol could improve collaboration in the WH/WDLS decision-making process, while facilitating dialogue and transmission of information between staff and families.

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