Developing guidelines for life-support therapy withdrawal in the home.

Dear Editor: We have been challenged with how to best meet the needs of patients and families wishing to withdraw life sustaining treatment (e.g., ventilator, pressor support, or circulatory assistance) in the home with hospice care. We developed a guideline based on our experiences in our inpatient care center, homes and local hospitals. Our major challenges have included clarifying the goals-ofcare before the move home and the withdrawal occurs, assuring a smooth transition from a hospital setting to the home, and coordinating logistics for support personnel, equipment and medications in the home. In addition, it is important to ensure communication within our agency, with the referring facility, and with interested family=designated decision makers. Our interdisciplinary group (IDG) also focuses on addressing cultural and spiritual needs. The IDG has developed and refined competencies for assessing and determining goals of care in the field, but it is essential to have a physician trained in palliative medicine present during the life-support therapy withdrawal (LSTW). Our goal is to have a timely, well coordinated, but sensitive process that includes appropriate internal and external resources and ancillary support. The guideline evolved through a rapid-cycle performance improvement process from a committed effort by nurses, social workers, spiritual counselors, physicians and managers from our departments handling admissions, triage, utilization review, crisis (continuous) care, and our rapid response home hospice team. Initial notification of all involved personnel occurs following a referral to our intake center or an admission nurse in the field. The main steps of the guideline are: