Guidelines for Decisions to Withhold or Withdraw Life-Sustaining Treatments (LST) in Adult ICU

Objective The French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Physical Medicine and Rehabilitation (Société Française de Médecine Physique et de Réadaptation (SOFMER)) aimed at providing guidelines for decisions to withhold or withdraw life-sustaining treatments (LST) in adult ICU.Design A consensus committee of 20 experts from the SFAR and the SOFMER was convened. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.Methods 3 fields were defined: (1) modalities of the LST decision-making process; (2) modalities for implementing an LST decision; (3) Relationships with family members, communication, disagreements, and conflicts. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE® grid method.Results The experts' work on synthesis and application of the GRADE® method resulted in 9 recommendations. Among the formalized recommendations, 1 was found to have a high level of evidence (GRADE 1), and 2 had low levels of evidence (GRADE 2). For 6 recommendations, the GRADE® methodology could not be fully applied, resulting in an expert's opinion. 2 questions could not be answered due to a lack of literature. After 1 round of rating, strong agreement was reached for all the recommendations.Conclusions There was strong agreement among experts to provide recommendations to improve practices for decisions to withhold or withdraw LST in the adult ICU.