19.7 (5.8) Withholding and withdrawing life sustaining treatment Flashcards
How do withholding and withdrawing life sustaining treatment differ? What is the expectation in both situations?
Withholding LST - deliberate decision not to initiate tx aimed at prolonging life
Withdrawing LST - involves removing medical intervention without which life is not expected to continue due to the patient’s underlying health status
expectation in both situations is that patient will die due to natural progression of underlying illness
What are the steps that should be taken in deciding to withhold or withdraw life sustaining treatment from a patient?
Box 19.7.1
1. Consider the legal and ethical framework for withholding/withdrawing LST
- Assess the consequences of utilizing or forgoing LST in this particular instance
- Assess the patient’s decision making capacity
- Make a decision regarding LST
- If the decision to withhold/withdraw LST is made, make a tx plan to actively manage resulting symptoms and provide support to patients/families and health care providers
What is the relationship between a physician’s knowledge of the legality regarding withholding/withdrawing LST and the aggressiveness of the care provided?
poor clinician knowledge associated with higher levels of legal defensiveness and consequently more aggressive and unjustified tx at the end of life
Why would legally differentiating between withholding and withdrawing LST create a problem for patients and families?
From a bioethical perspective no difference
Withdrawing LST is often perceived by patients and families as having a direct causation in a patient’s death
If only withholding LST was acceptable then time limited trials of interventions would not be permitted and patients would need to remain on the tx until death
A patient presents to the hospital with very advanced met breast ca and hepatic failure as a result. The patient has a prognosis of hours to days. ICU is consulted and states that life sustaining tx is not going to benefit the patient. The patient demands admission to the critical care, including intubation and CPR if they deteriorate. Does the principle of autonomy apply in this situation?
No - patients do not have the right to demand harmful or non-beneficial treatments
“In dealing with these cases, some authors warn that an uncritical acceptance of pt autonomy may compromise self-determination by forcing pts/families to make decisions for which they lack the prerequisite knowledge.”
A physician opts to withhold life sustaining tx from a patient with COPD and pneumonia. What are three reasons that withholding treatment based on unilateral determinations of futility is problematic?
- There is no accepted definition of futile treatment and it is often unclear to physicians what this actually means in clinical practice
- What a clinician judges as futile is inherently subjective and influenced by their own values
- Using futility as the basis for a unilateral decision to withhold/withdraw tx enables clinicians to avoid having difficult yet beneficial conversations that are frequently needed to bridge the gap between unrealistic family expectations and clinicians’ prognosis
Double effect suggests it is impossible to avoid all harmful actions in the provision of palliative care.
List 3 features an act must have in order to be morally acceptable, despite double effect
- The nature of the act must be good or at least morally neutral
- The harmful effect must be forseen but not intended
- the harmful effect must not be a way of producing the good effect
How do competence and capacity differ?
Competence is a legal determination made by the courts and relates to the presence or absence of global decision making capacity
Capacity (decision making) - cognitive ability to participate in making medical decisions
What three steps would you take to determine a patient’s decision making capacity?
- objective testing of cognition and reasoning should be performed (ie. MacArthur Competence Assessment Tool)
- Assess for presence of depression which will not only impair cognitive function but may also significantly bias pt preferences against LST
- AT MINIMUM, address the following questions:
a. Does the patient understand the relevant information?
b. Does the patient appreciate the medical consequences of the various tx options?
c. Can the patient manipulate the information in a rational manner and state the reasons for making a particular decision?
d. Can the patient communicate the choice?
What type of model should a physician use when making a decision about withholding or withdrawing LST? What three steps are involved in this?
Shared decision making model where patients or their surrogates are encouraged to participate in selecting appropriate treatment options in accordance with the patient’s values
- Clinician provides patients, families, or surrogates with information about the likely consequences of utilizing or forgoing LST
- Clinician gains understanding of the patient’s values and goals
- Clinician makes a recommendation based not only on their own medical expertise but also on their knowledge of the patient’s values and goals and their assessment of whether using LST would achieve those
list three benefits of advanced directives
- promote early discussion about death and dying
- help alleviate anxiety about future decions
- guide decision making when capacity is lost
- reduce stress, depression, anxiety in surviving relatives
List three limitations of advance directives
individuals find it difficult to predicting future preferences of care
only a minority of patients have completed advance directives
Often when an AD does exist they are difficult to locate or too vague to be of any use
A shared decision has been made to withdraw life sustaining treatment from a ventilated patient in the ICU. Name four actions that could be taken after the decision is made to ensure comfort for all involved?
document decision making process
involvement of palliative care teams
clinicians should inform families of expected signs of dying process (skin changes, cheyne stokes etc)
Give an approximation of how long pt will survive (with caveat it may be longer)
provide psychosocial support to families and clinicians
referral to psychology, social work, chaplaincy if appropriate
Allow families adequate time to say goodbye
bereavement support after the patient has died
forum for staff to debrief may decrease burnout and distress amongst staff
What is the average survival time after withdrawal or cessation of hemodialysis
8-12 days
List four complications of artificial nutrition and hydration in a patient with advanced illness
line sepsis aspiration PNA diarrhea hypervolemia pressure ulcers pain local infection at feeding tube site
