A Community of Exceptional Nurses
University of Washington/Harborview Medical Center - Integrating Palliative and
Critical Care Program: Withdrawal of Life-Sustaining Measures Order Form
A two page form for intensive care doctors and nurses containing a comprehensive
list of steps to follow when withdrawing life-sustaining measures and a list of
principles for withholding and withdrawing life-sustaining treatment.
Educational Tools - Clinician Education
University of Washington
Harborview Medical Center
325 9th Ave., Box 359762
Seattle WA 98104
J. Randall Curtis, M.D., M.P.H.
How the grantee used this instrument:
Physicians and nurses read and signed the withdrawal of life-sustaining measures
order form before beginning the recommended withdrawal procedures.
hospital, clinical training, grand rounds, clinical information, champions, educational
To use this tool:
You may print and copy this tool from this site. The information contained therein
will need to be adapted for your site. See the following website for updated versions:
Treece PD, Engelberg RA, Crowley L, Chan JD, Rubenfeld GD, Steinberg KP, Curtis
JR. Evaluation of a standardized order form for the withdrawal of life support in
the intensive care unit. Critical Care Medicine 2004; 32:1141-1148.
To view this tool:
Withdrawal of Life-Sustaining Measures Order Form - 2 page
(Viewing PDF files requires downloading and installation of the free
Adobe Acrobat Reader.)
Posted: July 2006
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Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation
dedicated to long-term changes in health care institutions to substantially improve
care for dying people and their families.
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