Standards › Standard 35 › Policies
Policy · CRT-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 35.6
At a glance
- Every decision to withdraw life-sustaining treatment is documented (CRT-FRM-004).
- The decision involves the responsible clinicians and the family.
- A comfort plan is in place before treatment is withdrawn.
- The patient’s known wishes are recorded and followed.
- Stop and get help straight away if: life-sustaining treatment is withdrawn with no documented decision.
1. Purpose
To make end-of-life decisions open, documented, and made with the family (35.6).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Decisions to stop life-sustaining treatment are among the hardest in medicine. A written protocol, with the patient or family and the team, makes the decision careful and respectful.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Intensivist | Leads the decision and documents it | Clinical director |
| Family and patient representative | Take part in the decision | Intensivist |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Discuss.
- Discuss the prognosis and options with the responsible clinicians and the family.
Key point: Discussed.
Step 2. Decide and document.
- Record the decision, the people involved and the patient’s wishes (CRT-FRM-004).
Key point: Documented.
Step 3. Plan comfort.
- Set the comfort plan before treatment is withdrawn (HSP-SOP-003).
Key point: Planned.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Withdrawal decisions with documentation complete | 100% | Quarterly | Intensivist | Escalate to the clinical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| CRT-FRM-004 | Withdrawal of treatment decision record | Record |
| HSP-SOP-003 | Care of the dying patient (existing) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the Surviving Sepsis and critical care monitoring guidance, the NEWS2 early warning score (Royal College of Physicians, 2017), the Lancet Commission on Palliative Care (2018), and the WHO Global Patient Safety Action Plan 2021–2030. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)