Withholding & Withdrawal of Life-sustaining Treatment

Withholding & Withdrawalof Life-sustaining Treatment Rels 300/Nurs330 7November 2013 300/330 - appleby

Of Life and Death: Ch.5http://www.parl.gc.ca/35/1/parlbus/commbus/senate/com-e/euth-e/rep-e/lad-tc-e.htm Withholding = not starting treatment that has the potential to sustain life Withdrawing= stopping treatment that has the potential to sustain life 300/330 - appleby Voluntary = Nonvoluntary = Involuntary = Competent = Incompetent =

What counts as a life-sustaining treatment? • any medical intervention, technology, procedure, or medication that is administered to a patient in order to prolong a patient’s life • treatment may or may not relate specifically to the underlying condition or disease of the patient • examples: respirators, blood transfusions, kidney dialysis, antibiotics, CPR, artificial nutrition and hydration 300/330 - appleby

Case Study: Nancy Cruzan In the early morning of 11 January 1983, Nancy's car left a country road. It hit some small trees and a mailbox, slid about 210 feet, and flipped over. Nancy landed face down, motionless, 15 feet away from the car. A highway patrolman arrived ten minutes later. He examined Nancy and thought she was dead. After another nine minutes, the paramedics arrived. They started CPR. Nancy was without oxygen for an estimated 20 minutes. 300/330 - appleby

Although Nancy survived, she had irreparable brain damage. After being in a coma for 3 weeks, doctors determined that she was in a persistent vegetative state. In this state, she had no awareness of anything or anyone around her. She did have some brain stem function and had other reactions one normally associates with being alive, such as moving, reacting to light, sound and noxious stimuli, blinking her eyes, and the like. She grimaced, made stereotyped cries and sounds and had chewing motions. Her blood pressure was normal and she did not require a respirator. 300/330 - appleby

5 YEARS LATER After 5 years of tube feeding and medical care amounting to $130,000 per year, Nancy had undergone significant physical deterioration. Nancy’s parents requested that artificial nutrition and hydration be withdrawn. In their opinion, and supported by many of Nancy’s friends, Nancy would not want to continue to exist in this persistent vegetative state from which there was no hope of recovery. They applied for a court order to have her feeding tube removed. 300/330 - appleby

Protesters They were confronted with the perspectives of others for whom life in any condition, sustained by what-ever means, is of absolute value. To the latter, removal of the feeding tube would be morally wrong, as it would result in the patient’s death. Police arrested 19 people who tried to break into the facility and re-insert her feeding tube during the period before her death 300/330 - appleby

In the Courts The Missouri Supreme Court refused to allow Nancy’s parents to have the feeding tube removed. The Cruzan’s appealed this decision to the US Supreme Court. This court ruled that there must be “clear and convincing evidence” that the patient herself would not have wanted to be kept alive in this manner by tube feeding. Following testimony from Nancy’s friends, the County Court finally ruled that there was sufficient evidence to make this choice. 300/330 - appleby

After almost 8 years of being sustained by a feeding tube, the treatment was withdrawn; Nancy died 11 days later. 300/330 - appleby

Starvation? • Are food and water necessities of life that all humans owe to each other? • Is nutrition like clothing and shelter? For many Jews, Muslims and some Christians, this is their religious belief. Since Jewish authorities do not accept the concept of “brain death,” they would never agree to withdraw a feeding tube while a patient was still breathing. For some Christians, “sanctity of life”always takes precedence over determinations of “quality of life.” 300/330 - appleby

AUTONOMY • Patients may choose to accept or refuse any medical treatment. • Caregivers may try to convince patients to accept medical therapies that are of clear and likely benefit; but they may not impose them on a non-consenting patient. • Patients may request that treatments that are no longer desired be discontinued, even if this will hasten their death. • Substitute decision-makers may make these same decisions for incompetent patients. 300/330 - appleby

BENEFICENCE • Caregivers should support the health and well-being of their patients. • While artificial nutrition and hydration can be effective in supporting life, it can become burdensome or prolong suffering. • Where a medical treatment is futile (meaning that it will not restore a person to an acceptable level of functioning), it may not be in the best interests of the patient to initiate it. • Futile therapies may be withdrawn, even if death is thereby hastened. 300/330 - appleby

NON-MALEFICENCE • Artificial nutrition and hydration may at times be harmful, especially when a person is dying. • Many terminally ill patients do not experience hunger or thirst and do not ask for food or a feeding tube. • Tube feedings can cause nausea, vomiting, or elimination problems: these are harms. • Patients are harmed when their requests for withdrawal of treatment are not honoured. 300/330 - appleby

JUSTICE • Decisions concerning artificial nutrition and hydration should not be made on the basis of gender, race, age, compliance, or patient difficulty. • Patients who choose to accept nutritional support should not be denied it. • Nutritional support should not be forced on patients who do not want it. • Patient options should not be limited by caregiver bias. 300/330 - appleby

Ethical Significance of this case • Competent patients may refuse life-sustaining treatment. • Where the patient is incompetent, and recovery is not a possible outcome, a substitute decision-maker may request that life-sustaining treatment be withdrawn. • Artificial nutrition and hydration is a medical treatment that provides food when patients cannot eat. • This is analogous to an artificial respirator providing air when patients cannot breathe. 300/330 - appleby

What if an incompetent patient’swishes are not known? If no member of the health care team knows the patient’s preferences; If no member of the patient’s family seems to know what the patient would have chosen; then how will a decision about withholding or withdrawing life-sustaining treatments be reached? What is a “best interests”judgement? • One answer: http://www.ascensionhealth.org/index.php?option=com_content&view=article&id=115&Itemid=172 300/330 - appleby

“In determining what is in the patient’s best interests, the surrogate should consider: • the patient’s current level of physical, sensory, emotional and cognitive functioning; • the degree of pain resulting from the patient’s medical condition, treatment or termination of the treatment; • the amount of humiliation, dependence and offence against dignity that will probably result from the patient’s condition and treatment; • the patient’s life expectancy and chance for recovery both with and without the treatment; • the treatment options available to the patient; • the risks, side effects and benefits of each of those treatment options.” 300/330 - appleby

Palliative care/withdrawing and withholding treatmentUK Alzheimer's Society position statement “The use of a tube for artificial hydration and feeding should not be considered best practice in the provision of care of people in the advanced stages of dementia.” “The Society believes that it is inappropriate for a person with advanced dementia to be given artificial hydration and nutrition for the sole purpose of prolonging life…” 300/330 - appleby

Canadian Critical Care SocietyWithholding or Withdrawal of Life Support 2.2 Withholding/Withdrawal of Life Support-Is There a Difference? i) …there is no difference…if life support can be withheld, it can also be withdrawn iii) …it is generally better to provide treatment, with a strategy in place for later withdrawal if it is either of no medical benefit or proves too burdensome, than to withhold treatment altogether because of unfounded fears about treatment withdrawal. 300/330 - appleby

Case Studies in End-of-Life CareNancy B 300/330 - appleby

Case Summary: Nancy B Nancy B. was a 25-year-old Quebec woman hospitalized due to Guillain-Barré syndrome. Her condition had deteriorated to the point that she could not breathe without the assistance of a respirator. According to her doctors, her condition was irreversible; she would continue to decline until her death. With respirator support, Nancy would continue to live for the immediate future. If the respirator were to be withdrawn, she would certainly die. 300/330 - appleby

Nancy determined that she did not want to continue respiratory support. Due to her muscle atrophy, she could not remove the respirator herself. With full knowledge that removing the respirator would result in her death, she asked her caregivers to withdraw the respirator. Both her doctor and the hospital were reluctant to withdraw this treatment. 300/330 - appleby

Although patients have a clear right to refuse treatment, withdrawal of life-sustaining treatment with the knowledge that the patient would subsequently die was problematic. For some, their commitment to preserving life would not allow them to perform this action. Others feared that they would be prosecuted for homicide or assisting in a suicide,both criminal acts. 300/330 - appleby

Questions for Case Discussion • What was the primary ethical dilemma, faced by health care professionals, in the case of Nancy B.? • How do the 4 health care principles relate to this case? Explain. • Imagine you are an RN working with Nancy B. She tells you that it is her wish to have the life-sustaining equipment removed. What will you say to her? What actions will you take? 300/330 - appleby

Judicial and Legal Overview Nancy B. requests that her life-sustaining ventilator be removed. Nancy B. applies for an injunction against the medical staff at the Hotel-Dieu hospital. This injunction would force her doctors to remove the ventilator. The Quebec Superior Court decides that the respiratory support received by means of the ventilator is considered treatment, and as a patient who can provide informed consent, Nancy B. has the right to refuse treatment. 300/330 - appleby

The Quebec Superior Court also determines that a physician following through with Nancy’s wishes is not performing the act of assisted suicide. The Quebec Superior Court grants Nancy B.’s injunction by ordering that her doctors do follow through with her requests. The court allows a 30-day appeal period before the removal of Nancy’s ventilator. Following this 30-day period, Nancy’s ventilator is removed and she dies peacefully. 300/330 - appleby

Broadcast Date: Feb. 13, 1992After winning the right to refuse to treatment, the 25-year-old Quebec woman dies 'Nancy B' dies after winning the right to refuse treatment. The CBC Digital Archives Website. Canadian Broadcasting Corporation. Last updated: Jan. 28, 2004. http://www.cbc.ca/archives/categories/politics/rights-freedoms/sue-rodriguez-and-the-right-to-die-debate/nancy-b-dies-after-winning-the-right-to-refuse-treatment.html(3:05) 300/330 - appleby

Ethical and LegalSignificance of this Case This case clarified the difference between situations when a patient dies as a result of his/her right to refuse treatment, and situations when the death is a result of assisted suicide or euthanasia. The case also determined that artificial respiration is considered a form of treatmentwhich can therefore be refused by a competent person. DATE: February 1992 300/330 - appleby

Withholding & Withdrawal of Life-sustaining Treatment