Guidelines for Decisions to Withhold or Withdraw Life-Sustaining Treatments (LST) in Adult ICU - 11/10/26

Doi : 10.1016/j.accpm.2026.101892

Mikhael Giabicani ^a , Gérard Audibert ^b , Enora Atchade ^c , Flora Bastiani ^d , Elodie Brunel ^e , Marie Citrini ^f , Claire Dahyot-Fizelier ^g , Nicolas Engrand ^h , Clément Gakuba ⁱ , Agathe Kudela ^j , Yoann Launey ^k , Yann Le Guen ^l , Jonathan Lévy ^m , Olivier Maillé ⁿ , Jerome Morel ^o , Pierre-François Perrigault ^p , Sylvaine Robin ^q , Christelle Rosenstrauch ^r , Léa Satre-Buisson ^s , Pierre Trouiller ^t , Denis Frasca ^u , Elise Langouet ^v

^a Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Clichy, France

^b Department of Anesthesiology and Critical Care, Center Hospitalier Universitaire de Nancy, Hôpital Central, Nancy, France

^c AP-HP, Bichat-Claude Bernard Hospital, DMU PARABOL, Paris, France, Inflammation Research Center, Inserm UMR 1149, Paris, France

^d Department of Philosophy, University Toulouse 2 Jean Jaurès, Toulouse, France

^e Intensive Care Unit, CH Montauban, France

^f Patient Perspective, Sorbonne University, Paris, France

^g Department of Anesthesiology and Critical Care, University of Poitiers, CHU Poitiers, INSERM 1070, Poitiers, France

^h Department of Anesthesiology and Critical Care, Rothschild Foundation Hospital, Paris, France

ⁱ Department of Anesthesiology and Critical Care Medicine, Caen University Hospital, INSERM, Caen, France

^j Department of Surgical Anesthesiology and Critical Care, Henri Mondor University Hospitals, AP-HP, Créteil, France, Mondor Institute for Biomedical Research, INSERM, University Paris Est Créteil, Créteil, France, Ecole Nationale Vétérinaire d’Alfort, Maisons-Alfort, France

^k Department of Anesthesiology, Critical Care and Perioperative Medicine, University of Rennes – 2, rue Henri Le Guilloux, Centre Hospitalier Universitaire de Rennes, Rennes, France

^l Department of Anesthesiology and Critical Care, CHU Grenoble Alpes, Grenoble, France

^m Department of Physical Medicine and Rehabilitation - UR20201 Rehadapt Lab - Raymond Poincare Hospital, APHP-UVSQ GHU Paris Saclay, Garches

ⁿ Palliative Care Service, CHU Montpellier, SFAP, Montpellier, France

^o Department of Anesthesiology and Intensive Care Medicine, Center Hospitalier Universitaire de Saint-Étienne, Saint-Étienne, France

^p Department of Anesthesiology and Intensive Care Medicine, Gui de Chauliac, University Hospital, Montpellier University, Montpellier, France

^q Department of Anesthesia and Critical Care, Université Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France

^r Emergency Department, CHU Lille, Lille, France

^s Department of Anesthesiology and Critical Care, Hôpital Saint-Antoine, AP-HP, Sorbonne University, Paris, France

^t Department of Anesthesiology and Critical Care, Rothschild Foundation Hospital, Paris, France

^u Department of Anesthesiology and Critical Care, University of Poitiers, CHU Poitiers, INSERM CIC 1402, Poitiers, France

^v Department of Cardiovascular Anesthesia and Critical Care, CHU Bordeaux, Bordeaux, France

Abstract

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.

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Keywords : LST limitation decision, ICU, Ethics

Plan

Introduction

Quality of care

Aim of the guidelines

Definitions of terms used in these recommendations

Objectives

Methodology

General organization

Recommendation fields

Literature search

Outcome criteria

Formulating recommendations

Summary of results

FIELD 1: Prerequisites and procedures for a decision to withhold and/or withdraw treatments

Question 1.1: For healthcare teams in ICU, does the organization of regular multiprofessional meetings for reflection and discussion about patients’ care plans improve the quality of care?

Question 1.2: For patients admitted to ICU, does early identification of patient’s wishes improve the quality of care?

Question 1.3: In patients hospitalized in ICU, when a decision to withhold and/or withdraw LST is being considered, does the use of a local protocol for decision support and communication with relatives and close persons, compared with no such protocol, improve the quality of care?

Question 1.4: In patients hospitalized in ICU, when withholding and/or withdrawal of life-sustaining treatments is being considered, does the active participation of non-medical healthcare teams in collegial procedure meetings, compared with no active participation, improve the quality of care?

FIELD 2: Implementation modalities of decisions to withhold and/or withdraw life-sustaining treatments

Question 2.1: In critically ill patients hospitalized in ICU, following a decision to withdraw life-sustaining treatments, does the use of a standardized protocol for the administration of sedation, when initiating continuous deep sedation until death, improve the quality of care?

Question 2.2: In mechanically ventilated patients hospitalized in ICU, following a decision to withdraw life-sustaining treatments, does extubation, compared with gradual weaning, improve the quality of care?

FIELD 3: Relationships with relatives, communication, disagreements, and conflicts

Question 3.1: In relatives of patients hospitalized in ICU, does a supportive care strategy, following a decision to withhold and or withdraw life-sustaining treatments, improve the quality of care?

Question 3.2: In healthcare teams working in ICU, does training in communication with relatives, compared with no specific training, prevent conflicts between relatives and healthcare teams?

Question 3.3: In relatives of patients hospitalized in ICU, in cases of disagreement or conflict between relatives and healthcare teams regarding a decision to withhold and or withdraw life-sustaining treatments, does the involvement of a clinical ethics support structure or a mediation team, compared with usual care, improve the quality of care?

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Vol 45 - N° 6

Article 101892- novembre 2026 Retour au numéro

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Guidelines for Decisions to Withhold or Withdraw Life-Sustaining Treatments (LST) in Adult ICU - 11/10/26

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Results

Conclusions

Plan

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