Table 1.

Policies and guidelines for withholding (WH) or withdrawing (WD) life-sustaining therapy (LST) in the ICU

Country/region	Options to limit LST	Decision-maker for incapacitated patients	Guidelines and legal framework
Australia	WH and WD	Intensivist, family, friends	Regional (state) legislation, Statement on withholding and withdrawing treatment by CICM and ANZICS (2021) [25]:  The potential benefits of treatment must be weighed against the burden based on probability rather than certainty  There is no obligation to initiate therapy known to be ineffective, nor to continue therapy that has become ineffective  When any or all aspects of active treatment are to be withheld or withdrawn, consideration should be given to comfort care
Brazil	WH and WD	Intensivist in agreement with family, often requiring consensus of the referring physician and/or specialty	Resolution of the Brazilian Federal Council of Medicine (2006) [28]  In the terminal phase of serious and incurable diseases, the physician is allowed to limit or suspend procedures and treatments that prolong the patient's life, guaranteeing the necessary care to alleviate the symptoms […], respecting the patient will or her legal representative” Resolution from Sao Paulo State Medicine Council (2022) [29]:  Futile treatments should not be performed, even at the request of the patient or his/her relative  Regarding potentially inappropriate treatments, consensus between the healthcare team and the patient and his/her relatives is necessary for decisions
Canada	WH and WD	Intensivists for WH, substitute decision-maker (SDM) for WD	Provincial legislation, Position paper by the Canadian Critical Care Society (2017), Statement by the College of Physicians and Surgeons of Ontario (2023) [34, 35]:  Physicians are not required to perform CPR when it falls outside of the usual standard of care  WD of LST requires consent by patients or SDM. This is not required for WH, but SDM need to be informed  WD of LST is always associated with an appropriate increase in symptomatic treatment
China	WH, rarely WD	Intensivist and family	None
England	WH and WD	Intensivist	Guidelines by the General Medical Council (GMC) for treatment and care towards the end of life (2022) [37]:  There is no absolute obligation to prolong life irrespective of the consequences for the patient and his/her view  It is the treating physician's responsibility to make decisions in the patient's best interest  Consultation with family / carers and members of the healthcare team should be made before reaching a decision about LST
Hong Kong	WH and WD	Intensivist with participation of families	Guidelines of the Medical Council (2022) and Hospital Authority (2020) [27, 28]:  Futility can be viewed in the strict sense of physiologic futility which is assessed by the health care team. In other clinical situations where futility is considered, the decision involves balancing the burdens and benefits of the treatment towards the patient. As this involves QoL considerations and can be value-laden, the decision-making is a consensus-building process between the health care team and the patient and family. In Chinese culture, the concept of self may be different from the Western concept and is more of a relational one. The role of the family in decision-making may also be more important than that of Western societies  Doctors are not obliged to comply with requests that make inequitable demands on resources available to them  Symptom control, comfort care and emotional support to the patient should always be offered
Israel	WH, WD only of intermittent therapies	Senior intensivist after consultations with other stakeholders (family, caregivers, legal guardians appointed by the court)	The Dying Patient Act (2006) [42]:  A "dying patient" is defined as one who is not expected to survive for more than six months despite medical therapy  The law tries to balance between the sanctity of life as a critical value in Jewish law and the need to respect patients' autonomy. Patients' wishes should be respected as long as they do not include active euthanasia or active shortening of the dying process  This law permits WH of LST if they are futile or the patient refuses them. The law differentiates between continuous life-sustaining treatment which must not be withdrawn and intermittent treatment which may
Libya	(controversial)	Intensivist after consultation with family	None
Norway	WH and WD	Intensivist	Guideline by the Norwegian Directorate of Health (2013) [43]:  Decisions concerning life-prolonging treatment must be informed by what in the patient’s best interests, and by the patient’s own wishes. The attending physician has a duty to ensure that the benefits of LST outweigh the adverse effects on the patient from the treatment or the disease. If the basis for a decision is uncertain, treatment must be initiated until its benefit has been ascertained  No one can be required to administer life-prolonging treatment that is futile When life-prolonging treatment is withdrawn, palliative care should be continued
Poland	WH and WD (WD rarely used for invasive ventilation)	Intensivist consensus, often after consultations with other specialties	Guidelines by the Polish Society of Anaesthesiology and Intensive Care (2014) and Polish Society of Internal Medicine (2023) [47, 48]:  There is no obligation to initiate therapy known to be ineffective (futile), nor to continue therapy that has become ineffective. The medical assessment of previous treatment and medical history should be done by a committee consisting of medical professionals. Evaluation of assumed patient's best interest is the most important value  Therapeutic options and end-of-life treatment is discussed with the family which, however, cannot decide for the patient  When the decision to limit LST is taken, the palliative care interventions need to be continued