Ethics in Critical Care Medicine: Withdrawal and withholding treatment

1. Ethics in Critical Care Medicine: Withdrawal and withholding treatment Dr Lau Chun Wing ICU, Dept of Anaesthesia, PYNEH Division of Respiratory and Critical Care Medicine, Dept of Medicine, PYNEH July 2005

2. Withholding and Withdrawal of treatment • Legally no difference between not initiating treatment and withdrawing it • Common practice world-wide to withdraw life support from a terminally ill patient incapable of giving consent under certain circumstances • Generally considered to be ethically and legally distinct from assisted suicide and active euthanasia

3. Mutiple issues to consider • Medical • Ethical • Social • Cultural • Legal • Economic

4. Four basic ethical principles • The principle of beneficence • Kindness, goodness, doing of good • The principle of non-maleficence • Non-(act of doing evil, harmfulness), do no harm • The principle of justice • Respect for patients’ autonomy

5. Medical futility American Thoracic Society • The purpose of life support is not to prolong biological life without qualification; rather it is to sustain or restore a meaningful survival, where “meaningful” refers to a survival that can be valued and appreciated by the patient. Thus, life support is futile for patients who are irreversibly unconscious, and for those who cannot improve from a state of total dependence on intensive medical care and heavy sedation.

6. Criteria of medical futility • The disease process must be terminal • The disease process must be irreversible • Death must be imminent • All reasonable efforts have been made to extend the life of the patient • There has been no objection to withdrawal of life support by attending medical and nursing/paramedical staff and by the patient’s relatives. Lack of a clear definition of medical futility. The definition has become increasingly elusive as technology has pushed back the limits of what can be done to prolong both life and the process of dying, e.g. the recent Terri Schiavo case

7. Reasonableness • The resonableness of the efforts made by the doctor to preserve life must be judged on all surrounding circumstances, including resources available, demand for resources, and the prognosis of the patient. • Appropriate documentation should be made

8. Do not resuscitate orders • Active conservative management • Conservative management

9. Recommended clinical pathway for the determination of medical futility

10. Communication • Non-verbal communication always speaks louder than words

11. Empathy • Anxiety and sadness: “you seem to be too anxious” vs “sounds like you’re pretty fearful about what this all might mean” • Understanding: “you have not listened carefully to understand what I mean”; “Let mean explain to you again in greater details what the situation is” • Anger: “Don’t be so angry first. Just chill out, if you are so angry you won’t understand what I say?” vs “I’m hearing you right, you are angry about it. Can you let me understand what makes you so angry?” • “You are asking into so much details that even if I try to explain it may still be difficult for you to understand the complex pathophysiology” vs “I can feel that you love your father so much that you ask into such details. Let me try my best to help you understand.”

12. Establishment of time-limited goals based on clinical judgement • “If we see no signs that your father has improved over the next 72 hours, then we believe you should consider withdrawing life support. We believe your father is suffering and has essentially no change to regain any reasonable quality of life, and to withdraw life support would allow him a more peaceful and dignified death.”

13. Pearls • No respectable physician should be pushed by relatives into giving treatment that is not medically indicated • Good medical care and use common sense • Treatment with everything that should be done – not everything that can be done