INSTITUTING, WITHHOLDING, AND WITHDRAWING LIFE SUSTAINING THERAPY: ETHICAL PERSPECTIVES
- Awareness of the ethical issues involved in decisions to institute, withhold, and withdraw life-sustaining therapy.
- Differentiate between withholding and withdrawing therapy for reasons of deliberately causing a person's death (which is wrong) versus withholding and withdrawing therapy because the burdens outweigh the benefits (which may be appropriate).
- Describe an advance directive, durable power of attorney for health care, and living will and know how these are used in patient care.
- The ability to discuss with a patient the formulation of an advance directive.
- Know how to raise issues regarding life-sustaining therapies in caring for patients.
- The ability to deal with conflicted situations and recognize resources for help.
- Be able to apply critical thinking to analyze ethical conflicts, recognize possible courses of action, reach a decision, and justify that decision. (Dr. Thomasma's Ethical Workup Guide serves as a model for developing this skill).
- Responsible medical practice requires including the patient in decision making about life-sustaining therapy.
- A recognition that discussions about therapy can be difficult but are necessary for good medical care.
- A respect for life and desire to preserve life that recognizes that at times the burdens of therapy and the prognosis for recovery is such that it is appropriate to withhold or withdraw life-sustaining therapy.
REVIEWING ETHICAL PRINCIPLES
- Autonomy: An individual is a law unto himself/herself; the desires of an individual are self-determining.
- Informed consent
- Explanation, risks and benefits, alternatives, outcomes
- Patient demonstrates understanding
- Competence as a legal concept
- The capability to handle information as a medical concept
- Paternalism (parentalism?): The physician decides what is the patient's best interest without regard for the patient's wishes.
- Beneficence: Action done out of a genuine desire to do what is good for the patient. Unfortunately, one person's beneficence may be another's paternalism. There are three elements to beneficent behavior for a physician:
Technical---one possesses appropriate skills and knowledge
Human---a willingness and ability to behave compassionately
Ambiguous---the attempt to choose and recommend therapeutic options in a way that respects patient autonomy.
- Non-maleficence: avoid evil---defining evil is sometimes obvious and sometime not so obvious.
- Evaluating a situation: using the ethical workup guide
Assessing a clinical decision in a systematic manner can provide guidance and allow for consideration of multiple viewpoints, devise a course of action that is clinically and ethically sound, and create justification for why a particular course of action was chosen over another.
A good way to approach a decision is by using the Ethical Workup Guide devised by Dr. Thomasma. There are six steps:
Step 1: What are the facts of the case?
It is crucial to understand the medical facts of the case as well as the wishes of the patient and/or family.
Step 2: What are the values at risk in the case?
This requires considering who has a stake in the case---patient, physicians, nurses, hospital administration, society---and listing the values that are involved in decisions about this case.
Step 3: Determine the principal conflicts between values, professional norms, and between ethical axioms, rules, and principles.
Step 4: Determine possible courses of action, and which values and ethical principles each course of action would protect or infringe.
Step 5: Make a decision in the case.
Step 6: Defend this course of action.
Why choose one course over another? Are you holding that one principle or value is the most important? Are you seeking consensus? Are you willing to compromise?
PROVISION, WITHHOLDING, AND WITHDRAWAL OF LIFE SUSTAINING THERAPY
- Attempt to have these decisions before a crisis: ADVANCE DIRECTIVES
- Living will and durable power of attorney for health care
- Discussing patient preferences rather than just having a piece of paper.
- The crucial point is that the wishes of patient are a central factor in decisions about instituting, withholding, and withdrawing life sustaining therapy.
- In discussions with patients and/or family contextualize decisions within the clinical realities and a commitment not to abandon the patient.
- Preserving life is tempered by a recognition of mortality
- Life-sustaining therapies are medical treatments with indications and contraindications.
- Avoid focus on a specific therapy: rather present a plan that will meet achievable patient goals, limit suffering, and ensure that the person is not abandoned to illness.
- Principles and some rules of thumb
- The obligation to preserve life
This is part of the role of the physician. Life is generally considered a great good and thus beneficence suggests that doctors normally act to preserve life and non-maleficence mandates that doctors never directly take life.
- Important distinctions and concepts
- The right to refuse treatment : competent patients can refuse treatment and their refusals are to be accepted unless there is serious doubt about competence (for whatever reason) or fears of coercion.
- Withholding versus withdrawing therapy : ethically there is not felt to be a significant distinction between the two, although sentiment and emotion may make withdrawal far more difficult than withholding therapy.
- Terminal versus non-terminal illness : the obligation to institute therapy changes depending on the clinical situation. For example, if death is imminent from metatstatic cancer, the ethical obligation to preserve life is tempered, even if there remains the traditional prohibition against taking life directly.
- Intention and killing : the intention to cause the death of a patient whether by omission or commission is generally considered wrong.
- Killing versus letting die : the difference may occasionally be blurred but that does not mean there is not a difference.
- There is no ethical obligation to institute futile treatment : but there may be other obligations and the notion of what constitutes futility is not always clear.
- Cost is not to be used by the physician as a criterion for bedside rationing. Cost is a valid concern on a social level, but without clear standards for limiting treatment in individual cases, decisions are arbitrary and ill-advised.
- How to discuss these issues
- Come up with a care plan
- Don't offer what you think won't work
- Be willing to explain why some things won't work
- Be willing to listen to the patient
- Give people time, if possible
- Don't ask family members if patient is capable of decision
- If patient is incapable then there are two things you should NOT ask the family: what the proxy or family member wants, and whether or not to withhold, withdraw, or start life-sustaining therapy. Remember, the job of the proxy is to convey what he or she thinks the patient would want. The job of the doctor is to make a recommendation. Do not ask: “Should we put your mother on the ventilator?” Rather, ask: “Given this clinical situation, here are the options that I recommend. Please help me to understand what your mother would want.”
- Potential ethical disaster areas
- Patient and/or family demands futile therapy.
- Who determines futility? Differing ideas as to what is effective.
- What is the meaning of the treatment to the person to the person and what are they really asking? (e.g., are they afraid that if they agree to a DNR then the person will get less attentive care?)
- Can you address their concerns in a manner that is medically reasonable?
- If not, then what? Fight or go with the flow?
- No advance directive, children in disarray.
- Talk with them individually if you can
- Get help from social workers or ethics consult
- Remember the family is the one that's fragmented, not you.
- Advance directive in place, family does not like it. Check your local law, but ethically the informed wish of the person should be followed.
- Family members seem overly anxious that the relative die.
- Physician's obligation remains to be the advocate of the patient.
- May need to seek legal assistance
A 40 year old man comes in for a history and physical. He feels well but decides that it is time to “get checked out.” His history, physical, and appropriate screening laboratory studies are all within normal limits. He appears to be a healthy man. During a session in which you discuss some preventive health measures like seat belt use, risks for sexually transmitted diseases, exercise, and nutrition you raise the question of advance directives.
How would you broach this issue? What would be a good opening line? If the individual does not have an advance directive, how would you explain it? When does a durable power of attorney and/or living will come into effect in Illinois?
A 35 year old woman develops endocarditis and acute aortic regurgitation. She is admitted to the hospital in severe heart failure with a blood pressure of 90/40, a temperature of 103, a BUN of 60 and Cre of 4.2, and left sided weakness. There is evidence of septic embolization. The patient is very ill, somewhat confused, but seems capable of understanding and following direct commands. It is clear to you that she needs homodynamic stabilization and an emergent referral to cardiac surgery for possible valve replacement. The patient is accompanied by her husband, her mother and father, and two brothers.
How would you explain what is happening to the patient? Would you discuss these issues with her family? How would you obtain permission for treatment? What evidence would you use to decide if the patient is capable of decision-making? What do you do if there is conflict among the family members? If the woman is too sick to speak for herself, how do you decide who speaks?
A 75 year old. man with Alzheimer's disease is your patient at a nursing home. As part of his admission last year, he and his family were asked about advance directives but none had been formulated. As his physician, you found him quite confused but on three separate occasions you had asked him what he would want if he became very sick. Each time he said “Just let me die.” Now your patient is in the emergency room with a temperature of 103 and a large aspiration pneumonia. His ECG has changed and shows evidence of an inferior myocardial infarction. He is having runs of multifocal atrial tachycardia and his blood pressure and urine output are low. The patient's wife has died. He has a son and daughter, who do not get along, but who live in the area.
How would you proceed? What would you want to know from the children? What if they disagree?
A 62 year old. man has advanced multiple myeloma with plasma cell infiltration of numerous bones, hypocalcaemia (11.5), and a pneumococcal pneumonia. He has failed all available chemotherapy. Given the presence of pneumonia and the fragility of his bones, any attempts at CPR would likely not result in a good outcome. It is quite possible that his sternum would disintegrate with chest compressions.
How would you outline a care plan to the patient and family? What if they insisted on CPR?