Withholding and withdrawing life sustaining treatment

Question 1

Approach to decision making

Answer 1

1. Consider legal and ethical framework
2. Assess consequences to using or forgoing life sustaining treatment in given situation
3. Assess patient’s decision making capacity
4. Make a decision re: life sustaining treatment
5. If decision to withhold or withdraw LST is made, make a treatment plan for symptoms and support.

Question 2

1. Consider the legal and ethical framework

Answer 2

• Is it legal in my jurisdiction?
• what are the ethical principles relevant to a decision ?

Question 3

2. Assess the consequences of utlizing or forgoing life sustaining treatment in this instance?

Answer 3

• What is the patient’s prognosis?
• What are the current goals of care?
• What are the likely outcomes of LST?
  
  • Will it extend life?
  • What is the evidence?
  • How will it impact QOL?
  • What are the complications?
  • Will it facilitate other treatment aims?
• What are the likely outcomes of withholding/withdrawing LST in this patient?
  
  • How will it effect survival?
  • What is expected clinical course?
  • What symptoms might occur?
  • What is emotional impact?
  • Do these outcomes align with patient values?

Question 4

3. Assess patient’s decision making capacity

Answer 4

• Does the patient have the capacity to make this particular decision at this particular time?
• Formal capacity assessment documented
• Assess for depression
• Answer the following questions:
  
  • Does the patient understand relevant information?
  • Does the patient appreciate the consequences of all options?
  • Can the patient state a rational reason for decision?
  • Can the patient communicate that choice?

Question 5

4. Make a decision re: Life sustaining treatment

Answer 5

• shared decision making:
  
  • patient expert in values and goals
  • physician expert in medicine and whether choice align with pt values and goals
• If patient has capacity, what is his/her preference?
• If patient does not have capacity, Advanced directive or surrogate decision maker?

Question 6

Disagreements from clinical uncertainty, ethical dilemma, legal issue

Answer 6

• Clinical uncertainty –> medical evidence, expertise, consultation
• Ethical problems –> consider principles of beneficence, non maleficence, autonomy, justice. Ethics consultation
• Legal issues —> expert opinion
• Conflict:
  
  • intrateam conflict - seek advice from senior colleagues
  • team-family/patient - hospital policy, ethics,
  • between family and patient - focus on patient goals. Social work, psychology, spiritual care

Question 7

5. If decision to withhold/withdraw life sustaining treatment is made, make a plan for symptom management and support

Answer 7

• clear plan for treatment of symptoms
• good communication
• address spiritual distress

Question 8

Withholding versus withdrawing treatment

Answer 8

• no reason to differentiate between in western bioethics
• Withdrawing - act of commission
• Withholding - act of omission
• Some cultures have perception that withdrawing less acceptable than withholding.

Question 9

Difference between withdrawing/withholding and PAS?

Answer 9

• withholding/withdrawing declining treatment that is artificially sustaining life
• PAS provision of means to end a life prematurely
• Not the same

Question 10

Ethical principles of modern bioethics

Answer 10

• Beneficience
• Non maleficience
• Autonomy
  
  • patients do not have right to demand harmful and non beneficial treatments
• Justice
  
  • fair use of scarce resources
  • treat the patient in front of you or society as a whole

Proportionality

• LST should be foregone if it causes more harm than benefit

Futility

• Not recommended to use as a justification for withholding/withdrawing care
• no definition of futile
• judgment of futility is subjective
• enables clinicians to avoid difficult but beneficial conversations

Non Abandonment

• physician withdraws from therapeutic relationship without warning or reasonable alternative for care.
• clear messaging about non abandoning and making plan for next phase and sx management/death.

Question 11

Principle of Double Effect

Answer 11

• Nature of act must be good or morally neutral
• Harmful effect must be foreseen but not intended
• Harmful effect must not be a way of producing good effect
• Good effect must outweigh bad effect

Morally acceptable

Question 12

Hemodialysis

Answer 12

• more acceptable to many to withhold dialysis
• death from uremia not asymptomatic : pain, agitation, myoclonus, muscle twitching, dyspnea, pruritis, nausea
• discuss symptoms, time to death, place of death, prognosis

Question 13

Artificial hydration and nutrition

Answer 13

• unlikely to increase life expectancy in patients with advanced disease
• add to suffering or even decrease life expectancy
  
  • line sepis, aspiration, diarrhea, hypervolemia, pressure ulcers, pain, local infection, nausea
• some religions consider AHN to be a basic human right/care not medical treatment
• Legally AHN (US) is a medical procedure that can be withheld or withdrawn
• cause of death is the disease that causes inability to eat rather than lack of nutrition itself

Question 14

Withholding/withdrawing care in severe neurologic impairment

Answer 14

• Persistent vegetative state vs minimally conscious state
• PVS: not conscious, no pain, no dyspnea
  
  • focus on family? Patient has no interests
• MCS: intermittent consciousness and possibility for recovery
  
  • optimize conditions for recovery
  • attempt to communicate
  • if withdrawing care, do the same way as for non neurologically impaired people