Canadian Journal of Anesthesia

, Volume 46, Issue 5, pp 497–504

Ethical and practical considerations of withdrawal of treatment in the Intensive Care Unit

  • Gregg M. Eschun
  • Eric Jacobsohn
  • Daniel Roberts
  • Barney Sneiderman
Medical Ethics

Abstract

Purpose

To discuss the medical, ethical and legal basis of decisions to discontinue life-support therapy in the adult intensive care unit (ICU), and to provide practical guidelines for the discontinuation of life support therapy.

Source

Relevant articles were retrieved through Medline (1991-present; terms: ethics, life support discontinuation, double effect, beneficence, non-maleficence). Other sources include legal references, and personal files.

Principal Findings

Understanding the legal and ethical principles of autonomy, beneficence, non-maleficence and double effect are crucial when withdrawing life support therapy. The law respects a competent patient’s right to direct his/her healthcare but does not uphold his/her right to demand futile care. Surrogate decision makers can be used when the patient is incompetent, provided they are acting in the patient’s best interest, Euthanasia is illegal and the distinction between discontinuation of therapy and euthanasia is legally clear. Skilful administration of palliative therapy cannot be construed as euthanasia when the aforementioned ethical principals are respected. The various practical methods of discontinuing therapy are discussed. Every ICU should develop its own guidelines and a checklist to help caregivers during this difficult time. Caregivers must anticipate the mechanism of death and direct interventions at the symptoms that are likely to cause discomfort. Drugs and dosages must be individualized, and depend on the underlying disease, anticipated mechanism of death, and the patient’s pharmacological history. When prescribing a drug, the intention should be clear.

Conclusions

Appropriate discontinuation of therapy in the ICU allows patients a dignified and comfortable death.

Résumé

Objectif

Discuter des bases médicales, éthiques et juridiques de la suppression du maintien des fonctions vitales chez les adultes de l’unité de soins intensifs (USI), et proposer des directives à appliquer dans ce cas.

Sources

Des articles pertinents ont été choisis à partir de Medline (1991 -aujourd’hui; termes: éthique, suppression du maintien des fonctions vitales, double effet, complaisance, humanité. Les autres sources comprennent des références juridiques et des dossiers personnels.

Constatations principales

La connaissance des principes légaux et éthiques de l’autonomie, de la complaisance, de l’humanité et du double effet est cruciale quand on retire le maintien artificiel des fonctions vitales. La loi respecte le droit d’un patient apte à décider de ses traitements de santé, mais elle ne lui confirme pas le droit de demander de vaines thérapies. On peut traiter le patient inapte à décider en suivant les conseils d’un proche pourvu que ce dernier agisse dans le meilleur intérêt du patient. L’euthanasie est illégale et la distinction entre l’arrêt de la thérapie et l’euthanasie est claire. L’administration adéquate d’une thérapie palliative ne peut être interprétée comme de l’euthanasie quand les principes éthiques susmentionnés sont respectés. Les différentes façons de supprimer la thérapie sont examinées. Chaque USI doit formuler ses propres directives et une liste récapitulative pour aider le personnel soignant pendant ces moments difficiles. Le personnel doit prévoir le mécanisme de la mort et les interventions directes sur les symptômes qui sont susceptibles de causer de l’inconfort. Les médicaments et leurs doses doivent être individualisés en fonction de la maladie sous-jacente, de la mort anticipée et des antécédents pharmacologiques du patient. Lintention doit être claire quand on prescrit un médicament.

Conclusion

Le retrait adapté de la thérapie à l’USI permet au patient de mourir dignement et sans souffrance.

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Copyright information

© Canadian Anesthesiologists 1999

Authors and Affiliations

  • Gregg M. Eschun
    • 1
  • Eric Jacobsohn
    • 1
  • Daniel Roberts
    • 1
  • Barney Sneiderman
    • 2
  1. 1.Section of Critical CareUniversity of Manitoba, Health Sciences CentreCanada
  2. 2.Faculty of LawUniversity of ManitobaCanada

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