Withdrawal of Life-Sustaining Measures Order Form - University of Washington Schools of Medicine and Nursing

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 posters

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: http://depts.washington.edu/eolcare .

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 PDF
(Viewing PDF files requires downloading and installation of the free Adobe Acrobat Reader.)

Posted: July 2006

Return to top

Return to the University of Washington School of Medicine and Nursing

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.

Your Feedback