of Life-Sustaining Treatment
the medicine wards, you will have patients who are receiving treatments or
interventions that keep them alive, and you will face the decision to discontinue
these treatments. Examples include dialysis for acute or chronic renal failure
and mechanical ventilation for respiratory failure. In some circumstances,
these treatments are no longer of benefit, while in others the patient or
family no longer want them.
is it justifiable to discontinue life-sustaining treatments?
the patient has the ability to make decisions, fully understands the consequences
of their decision, and states they no longer want a treatment, it is justifiable
to withdraw the treatment.
Treatment withdrawal is also justifiable if the treatment no longer offers
benefit to the patient.
do I know if the treatment is no longer "of benefit?"
In some cases, the treatment may be
"futile"; that is, it may no longer fulfill any of the goals of medicine.
In general, these goals are to cure if possible, or to palliate symptoms,
prevent disease or disease complications, or improve functional status. For
example, patients with severe head trauma judged to have no chance for recovery
of brain function can no longer benefit from being maintained on a mechanical
ventilator. All that continuation would achieve in such a case is maintenance
of biologic function. In such a case, it would be justifiable to withdraw
different standards apply to withholding and withdrawing care?
Many clinicians feel that it is easier to not start (withhold) a treatment,
such as mechanical ventilation, than to stop (withdraw) it. While there is
a natural tendency to believe this, there is no ethical distinction between
withholding and withdrawing treatment. In numerous legal cases, courts have
found that it is equally justifiable to withdraw as to withhold life-sustaining
treatments. Also, most bioethicists, including the President's Commission,
are of the same opinion.
the patients have to be terminally ill to refuse treatment?
Though in most cases of withholding or withdrawing treatment the patient has
a serious illness with limited life expectancy, the patient does not have
to be "terminally ill" in order for treatment withdrawal or withholding to
Most states, including Washington State, have laws that guarantee the right
to refuse treatment to terminally ill patients, usually defined as those having
less than 6 months to live. These laws do not forbid other patients from exercising
the same right. Many court cases have affirmed the right of competent patient
to refuse medical treatments.
if the patient is not competent?
In some cases, the patient is clearly unable to voice a wish to have treatment
withheld or withdrawn. As with DNR orders,
there are two general approaches to this dilemma: Advance
Directives and surrogate decision makers.
This is a document which indicates with some specificity the kinds of
decisions the patient would like made should he/she be unable to participate.
In some cases, the document may spell out specific decisions (e.g.
Living Will), while in others it will designate a specific person
to make health care decisions for them (i.e. Durable Power of Attorney
for Health Care). There is some controversy over how literally Living
Wills should be interpreted. In some cases, the document may have been
drafted in the distant past, and the patient's views may have changed.
Similarly, some patients do change their minds about end-of-life decisions
when they actually face them. In general, preferences expressed in a Living
Will are most compelling when they reflect long held, consistently stable
views of the patient. This can often be determined by conversations with
family members, close friends, or health care providers with long term
relationships with the patient.
In the absence of a written document, people close to the patient and
familiar with their wishes may be very helpful. (See Advance
Care Planning.) The law recognizes a hierarchy of family relationships
in determining which family member should be the official "spokesperson,"
though generally all close family members and significant others should
be involved in the discussion and reach some consensus. The hierarchy
is as follows:
Legal guardian with health care decision-making authority
Individual given durable power of attorney for health care decisions
Adult children of patient (all in agreement)
Parents of patient
Adult siblings of patient (all in agreement)
if I'm not sure if the patient is competent?
Sometimes the patient is awake, alert, and conversant, but their decisions
seem questionable or irrational. First, it is important to distinguish an
irrational decision from simple disagreement. If you feel strongly that a
certain course of action is "what's best" for the patient, it can seem irrational
for them to disagree. In these situations, it is critical to talk with the
patient and find out why they disagree.
are presumed to be "competent" to make a treatment decisions. Often it's better
to say they have "decision making capacity" to avoid confusion with legal
determinations of competence. In the courts, someone's competence is evaluated
in a formal, standardized way. These court decisions do not necessarily imply
anything about capacity for making treatment decisions. For example, an elderly
grandfather may be found incompetent to manage a large estate, but may still
have intact capacity to make treatment decisions.
In general, the capacity to make treatment decisions, including to withhold
or withdraw treatment, is considered intact if the patient:
understands the clinical information presented
appreciates his/her situation, including consequences with treatment refusal
is able to display reason in deliberating about their choices
is able to clearly communicate their choice.
the patient does not meet these criteria, then their decision to refuse treatment
should be questioned, and handled in much the same way as discussed for the
clearly incompetent patient. When in doubt, an ethics consultation may prove
a psychiatry consult required to determine decision making capacity?
A psychiatry consult is not required, but can be helpful in some cases. Psychiatrists
are trained in interviewing people about very personal, sensitive issues,
and thus can be helpful when patients are facing difficult choices with fears
or concerns that are difficult to talk about. Similarly, if decision making
capacity is clouded by mental illness, a psychiatrist's skill at diagnosis
and potential treatment of such disorders can be helpful.
depression or other history of mental illness mean a patient has impaired
decision making capacity?
Patients with active mental illness including depression should have their
decision making capacity evaluated carefully. They should not be presumed
to be unable to make treatment decision. In several studies, patients voiced
similar preferences for life-sustaining treatments when depressed as they
did after treatment of their depression.
and other mental disorders should prompt careful evaluation, which may often
be helped by psychiatry consultation.
it justifiable to withhold or withdraw food or fluids?
This question underscores the importance of clarifying the goals of medical
treatment. Any medical intervention can be withheld or withdrawn, including
nutrition and IV fluids. At all times, patients must be given basic humane,
compassionate care. They should be given a comfortable bed, human contact,
warmth, and be kept as free from pain and suffering as possible. While some
believe that food and fluids are part of the bare minimum of humane treatment,
both are still considered medical treatments. Several court cases have established
that it is justifiable to withhold or withdraw food and fluids.
it justifiable to withhold or withdraw care because of costs?
It is rarely justifiable to discontinue life-sustaining treatment for cost
reasons alone. While we should always try to avoid costly treatments that
offer little or no benefit, our obligation to the patient outweighs our obligation
to save money for health care institutions. There are rare situations in which
costs expended on one terminally ill patient could be clearly better used
on another, more viable patient. For instance, a terminally ill patient with
metastatic cancer and septic shock is in the last ICU bed. Another patient,
young and previously healthy, now with a self-limited but life-threatening
illness, is in the emergency room. In such cases, it may be justifiable to
withdraw ICU treatment from the terminally ill patient in favor of the more
viable one. Even so, such decisions must be carefully considered, and made
with the full knowledge of patients and their surrogate decision makers.