Review Articles Decision tools for life support: A review and policy analysis M. Giacomini, PhD; D. Cook, MD; D. DeJean, BA; R. Shaw, MA; E. Gedge, PhD V ariations in the administra- tion, withdrawal, and with- holding of advanced life sup- port in the intensive care unit (ICU) have been well documented (1– 4). Although much of this variation may re- flect differences in patient needs and pref- erences, it may also be influenced by less- patient-centered factors such as ICU bed or resource availability, prevailing cul- tural norms, and physician practice styles. Variations in life support should be socially justifiable and reflect legitimate differences in patients’ values. Inconsistencies in the use of life sup- port have led to the development of deci- sion “tools” (protocols, guidelines, check- lists, ethics policies) to standardize practices and promote patient-centered care. Advance directives, for example, have been promulgated as a method of recording resuscitation and other ad- vanced life-support preferences. With re- spect to life-support withdrawal, Sjokvist et al. note that, “The process of withdraw- ing life-sustaining treatment requires not only diligence and conscience but also a systematic approach. Local protocols might be one way to improve this pro- cess” (p. 236) (5). The Society for Critical Care Medicine in 1990 encouraged the “establishment of written institutional policies and protocols for decisions to ter- minate life-sustaining care” and recom- mended that “institutional checklists that identify the universe of decisional consid- erations in various categories. . . should be developed” (p. 957) (6). As an example, standardized comfort care order forms evaluated in a before-and-after study helped ICU nurses and physicians prepare for withdrawal of life support and in- creased medication use at the end of life, without influencing the time to death or quality of the dying experience (7). Although guidelines and decision tools have become widely used in many areas of medicine, the relevance of such policies to life-support dilemmas is less clear. Life-support decisions are complex, emotionally difficult, and often designed to achieve “a good death” rather than any measurable degree of health. The experi- ences generated by life-support decisions become powerful, lifelong memories for those involved. Process matters as pro- foundly as outcome. Making life-support administration, withholding, and with- drawal decisions means facing dilemmas that arise from not only clinical Objective: To identify, describe, and compare published doc- uments intended to guide decisions about the administration, withholding, or withdrawal of life support in critical care. Design: Review article. Setting and Sources: Publicly available, English-language guidelines or decision tools for life support, identified through systematic literature search. Measurements and Main Results: Forty-nine documents were included and coded for authorship, source, development method- ology, format, and positions taken on 12 common life-support issues. Sources were independent academics (n  21, 43%), professional organizations (n  19, 44%), and provider organiza- tions. Eighteen documents (37%) described no development method. Twenty-three (47%) were produced collectively (e.g., by committees or consensus conference), 7 (14%) mentioned a lit- erature review, and 2 (4%) were based upon the author’s profes- sional experience. Tools differed in format and focus; we char- acterize three types as decision schemas (involving clinical practice algorithms; n  7, 14%), decision guides (reviewing legal or professional positions; n  29, 59%), and decision counsels (more discursive and focusing typically on ethical issues; n  13, 27%). Tools addressed 12 common life-support issues: advance directives (67%), resource considerations (51%), ICU discharge criteria (27%), ICU admission criteria (16%), whether withholding differs from withdrawing life support (59%), whether nutrition and hydration decisions are different from decisions about other types of life support (61%), euthanasia (49%), double effect (47%), brain death (35%), special considerations for patients in a persistent vegetative state (51%), potential organ donors (12%), and preg- nant patients (10%). Positions on these key life-support issues varied. Conclusions: Published tools for guiding life-support decisions vary widely in their genesis, authorship, format, focus, and prac- ticality. They also differ in their attention to, and positions on, key life-support dilemmas. Future research on decision tools should focus on how users interpret and apply the messages in these tools and their impacts on practice, quality of care, participant experiences, and outcomes. (Crit Care Med 2006; 34:864–870) KEY WORDS: life support; guidelines; protocols; ethics; decision tools; decision-making From the Department of Clinical Epidemiology & Biostatistics (MG, DC, DdeJ), Centre for Health Eco- nomics and Policy Analysis (MG, DdeJ), Department of Medicine (DC), Department of Sociology (RS), and De- partment of Philosophy (EG), McMaster University, Hamilton, Ontario, Canada. All authors report no financial interests in conflict with the content of this article. Funded in part by grant MOP-43983 from the Canadian Institutes of Health Research (CIHR), Ottawa, Ontario, Canada. Dr. Giacomini was supported during this study by a Scholar Award from CIHR; Dr. Cookholds a Canada Research Chair of the CIHR. This work benefited from the resources and collegial environment of the Centre for Health Economics and Policy Analysis, which is funded in part by the Ontario Ministry of Health and Long Term Care (Toronto, On- tario, Canada). The authors retain sole responsibility for the con- tent of this article and its conclusions. Not for distri- bution, quotation, or citation without permission. Copyright © 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01.CCM.0000201904.92483.C6 864 Crit Care Med 2006 Vol. 34, No. 3