Withdrawal of life sustaining therapies for awake patients in critical care: The benefits of a collaborative intensivist & palliative care approach.

Around 13% of patients admitted to critical care in Europe die in the Intensive Care Unit (ICU). In the United Kingdom, 15%-20% of patients admitted to critical care do not survive to discharge. Of those that die in ICU, 80% do so following an active decision to withdraw life-sustaining therapy (WLST). With the increasingly aged and co-morbid critical care population entering the ICU, there is an ongoing need for timely, considered discussions both when initiating life sustaining therapies, and also for effective, sensitive communication and management when it comes to withdrawing. In the case of WLST, very little data exists reflecting the proportion of scenarios involving an 'awake' patient with capacity to take part in this decision. It is, however, generally thought to be a small proportion. Most intensivists will therefore have less experience in this process, which perhaps is more representative of the work of our palliative care colleagues. We aim to discuss the most common scenarios in which WLST may occur in the awake and capacitous patient in critical care, the challenges to providing this, and some practical advice on how to perform it well, including the benefits of early interdisciplinary collaboration alongside palliative care.