Life Support, Withholding and Withdrawal of
Synonyms
Definition
Withdrawal (WD) of life support means the discontinuation of crucial life support, whereas withholding (WH) of life support means that life-sustaining treatments will be foregone. A “do-not-resuscitate” order is an example of the WH. WH/WD of life support does not seek to hasten patient death: it is not euthanasia or physician-assisted suicide. WH/WD of life support shifts the critical care goals from cure to comfort. This reduces unnecessary suffering by patients and their families as death approaches and avoids inappropriate patient management.
Background
Continued intensive care may not be beneficial for terminally ill patients. Issues with the WH/WD of life support have attracted public comment. Technological improvements in life-sustaining measures now allow terminally ill patients to survive longer in the intensive care units (ICUs). Provision of optimal care for dying patients and their families has become an important feature of ICU quality improvement efforts. Death in the ICU frequently follows WH/WD of life support (Prendergast et al. 1998). In a North American study, the proportion of patients dying after WH/WD of life support increased from 51 % to 90 % during a 5-year study period (Prendergast et al. 1998). The reasons for limiting the application of life-sustaining measures include patient refusal of such procedures, a low probability of improvement, or failure of a patient to get obtain any benefit from a prior therapeutic procedure. WH/WD decisions are always influenced by many factors. The possibility of future medical improvement and the nature of end-of-life (EOL) care feature prominently in discussions between caregivers and family members. Most societies have not reached a consensus on how to balance possible future medical improvement and apparent present medical futility.
Ethical Principles Related to the WH/WD of Life Support
- 1.
Withholding and withdrawing of life support are equivalent.
- 2.
There is an important distinction between killing and allowing to die.
- 3.
The doctrine of the “double effect” provides an ethical rationale for providing relief of pain and other symptoms using sedatives, even when this may have the foreseeable (but not intended) consequence of hastening death.
Distributive justice in terms of scarce medical resources is also frequently in play when WH/WD decisions are made. The principles of such justice include cost-effectiveness, cost utility, and cost-benefit analyses that prohibit unfair discrimination. In clinical situations, these ethical principles sometimes clash. Prioritizing the probable best interests of a patient at any given moment may be a useful approach.
Legal Aspects
The legal aspects of whether patients (or their surrogates) have a right to refuse any kind of medical intervention vary among countries. Many countries do not allow physician to make EOL care decisions based on a unilateral view of patient best interests. Resource to a judicial solution is a last resort appropriate only when repeated efforts, including referral to institutional Ethics Advisory Committees, have failed to create a consensus on WH/WD of life support.
Application
Clinical Settings
WH/WD of life support should be considered when patient survival is highly unlikely even with application of reasonable and available treatments. Also, WH/WD should be considered when the burden of interventions either being delivered or that could potentially be given outweighs any benefit to a terminally ill patient. An example of such a burden is inhumane suffering.
Method
Any decision to WD/WH life support is the conclusion of a complex process involving many factors including the characteristics of patients and their proxies. The process should begin soon after ICU admission. The use of a medical chart to identify indicators for employment of end-of-life care is helpful to improve both the quality and the nature of such care. ICU physicians do not have the authority to WD/WH life support, although such physicians are the appropriate professionals to evaluate possible clinical benefits of present or future therapies. Respect for the right of each patient to self-determination is the first principle of a WH/WD decision. If a patient retains analytical capacity, care levels should ideally be discussed with that patient. Patient autonomy can be expressed via the making of a living will or an advance health directive. To date, most ICU patients do not write advance directives, even in countries advocating patient autonomy in hospitals. If the care request expressed by a patient is not appropriate, the sharing of decision-making, in terms of end-of-life care, by both caregivers and patient family members, is important. The family must be given sufficient time, and adequate clinical information, to allow an appropriate decision to be reached. Physicians must ensure that families do not feel that a WH/WD decision is the only choice; alternative treatments should be offered. Effective communication is crucial to resolve conflicts between attending physicians, trainee doctors, nurses, and family members and to establish efficient advance care planning. A willingness to both listen and respond to family members is essential if communication is to be effective. The clinical care team should carefully define the clinical benefits of current or potential life support. The planned care should prioritize the physical, social, and spiritual comfort of the patient. All ICU therapies should be critically evaluated in terms of patient comfort. The caregiver team must deliver a pain-free death. Each patient must receive enough painkiller to alleviate pain and distress (Thompson et al. 2004). If such analgesia hastens death, the “double-effect” doctrine should not detract from the aim of ensuring patient comfort. The family should be kept informed throughout the entire process. Documentation of family conferences is extremely important to facilitate progress at future meetings, to improve advance care planning, and as evidence if legal disputes occur. Organ and tissue donation is an integral feature of end-of-life care decisions (see “ Family Preparation for Organ Donation”). Any request for organ or tissue donation should be made in a private room; families must be allowed to consider patient wishes in this regard. The family must be given time to accept the death prior to the posing of any such request.
No major ethical difference is evident between WH and WD of life support. Treatment should be based on patient benefit-burden assessment, and not on the psychological burdens experienced by clinicians and families. End-of-life care should continue after death; at that time, the family members become the patients.
Hospital Ethics Committee (HEC)
If a conflict in terms of end-of-life care arises between caregivers and the family, and this cannot be resolved via further communication, consultation with ethicists may be helpful. The first role of an HEC is to address the relevant ethical issues. Suggestions made by HEC support the use of best practice for each patient and such comments sometimes play important roles in countries in which WH/WD of life support is not legally supported. HEC have no distinct legal status in most countries; families are thus free to challenge HEC decisions in court.
Outcome
Relevant Factors
End-of-life care practice varies widely among countries and even among ICUs in the same country. Decisions are influenced by uncertainties in terms of patient outcome, patient preference, the extent of legal tolerance of WH/WD of life support, economic and home care burdens on patient families, and the extent of national medical coverage. Such choices are also influenced by aspects of medical culture such as ICU admission and discharge policies, social mores, and ethnic perceptions of death. Moreover, decisions are influenced by clinician experience and values; the availability of medical resources; current practice; the religious, psychological, and relational context of the patient and proxies; and the evolution of medical theories. Some quality domains of end-of-life care have been identified; these include (1) patient- and family-centered decision-making, (2) excellent communication, (3) continuity of care, (4) emotional and practical support, (5) symptom management and comfort care, (6) spiritual support, and (7) emotional and organizational support for ICU clinicians (Clarke et al. 2003). Poor communication between ICU staff and patient surrogates constitutes a major barrier to a desirable outcome.
Family Acceptance of WH/WD of Life Support
Conflicts between family members and medical staff are not infrequent during discussion of end-of-life decisions. Posttraumatic stress is common among those who share in such decisions (Azoulay et al. 2005). Proactive consultation with ethicists, advance care planning including discussion of palliative care, and regular well-planned ICU staff/family conferences improve family satisfaction. Longer intervals prior to life-support WD for patients with longer ICU stays (Gerstel et al. 2008) and provision of spiritual support were both associated with increased family satisfaction with care, as was extubation before death (Gerstel et al. 2008). However, unnecessary prolongation of dying creates family dissatisfaction. Uncertainty in terms of outcomes is a frequent cause of such prolongation, and unclear recommendations from physicians discussing end-of-life decisions are the principal source of dissatisfaction among family members. The use of imprecise and insensitive terminology during family discussions and a failure to understand the wishes of the family frequently create family dissatisfaction. The final levels of family and caregiver satisfaction are probably the best measure of end-of-life care practice. Encouraging caregivers to view acquisition of end-of-life skills as a lifelong educational process may be essential if the quality of end-of-life care is to be further improved.
Cross-References
References
- Azoulay E, Pochard F, Kentish-Barnes N et al (2005) Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 171(9):987–994CrossRefPubMedGoogle Scholar
- Clarke EB, Curtis JR, Luce JM et al (2003) Quality indicators for end-of-life care in the intensive care unit. Crit Care Med 31(9):2255–2262CrossRefPubMedGoogle Scholar
- Gerstel E, Engelberg RA, Koepsell T, Curtis JR (2008) Duration of withdrawal of life support in the intensive care unit and association with family satisfaction. Am J Respir Crit Care Med 178(8):798–804CrossRefPubMedPubMedCentralGoogle Scholar
- Prendergast TJ, Claessens MT, Luce JM, Prendergast TJ, Claessens MT, Luce JM (1998) A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med 158(4):1163–1167CrossRefPubMedGoogle Scholar
- Thompson BT, Cox PN, Antonelli M et al (2004) Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary. Crit Care Med 32(8):1781–1784CrossRefPubMedGoogle Scholar
- Truog RD (2008) End-of-life decision-making in the United States. Eur J Anaesthesiol Suppl 42:43–50CrossRefPubMedGoogle Scholar