Withholding and withdrawing life sustaining treatment Flashcards

1
Q

Approach to decision making

A
  1. Consider legal and ethical framework
  2. Assess consequences to using or forgoing life sustaining treatment in given situation
  3. Assess patient’s decision making capacity
  4. Make a decision re: life sustaining treatment
  5. If decision to withhold or withdraw LST is made, make a treatment plan for symptoms and support.
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2
Q
  1. Consider the legal and ethical framework
A
  • Is it legal in my jurisdiction?
  • what are the ethical principles relevant to a decision ?
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3
Q
  1. Assess the consequences of utlizing or forgoing life sustaining treatment in this instance?
A
  • What is the patient’s prognosis?
  • What are the current goals of care?
  • What are the likely outcomes of LST?
    • Will it extend life?
    • What is the evidence?
    • How will it impact QOL?
    • What are the complications?
    • Will it facilitate other treatment aims?
  • What are the likely outcomes of withholding/withdrawing LST in this patient?
    • How will it effect survival?
    • What is expected clinical course?
    • What symptoms might occur?
    • What is emotional impact?
    • Do these outcomes align with patient values?
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4
Q
  1. Assess patient’s decision making capacity
A
  • Does the patient have the capacity to make this particular decision at this particular time?
  • Formal capacity assessment documented
  • Assess for depression
  • Answer the following questions:
    • Does the patient understand relevant information?
    • Does the patient appreciate the consequences of all options?
    • Can the patient state a rational reason for decision?
    • Can the patient communicate that choice?
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5
Q
  1. Make a decision re: Life sustaining treatment
A
  • shared decision making:
    • patient expert in values and goals
    • physician expert in medicine and whether choice align with pt values and goals
  • If patient has capacity, what is his/her preference?
  • If patient does not have capacity, Advanced directive or surrogate decision maker?
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6
Q

Disagreements from clinical uncertainty, ethical dilemma, legal issue

A
  • Clinical uncertainty –> medical evidence, expertise, consultation
  • Ethical problems –> consider principles of beneficence, non maleficence, autonomy, justice. Ethics consultation
  • Legal issues —> expert opinion
  • Conflict:
    • intrateam conflict - seek advice from senior colleagues
    • team-family/patient - hospital policy, ethics,
    • between family and patient - focus on patient goals. Social work, psychology, spiritual care
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7
Q
  1. If decision to withhold/withdraw life sustaining treatment is made, make a plan for symptom management and support
A
  • clear plan for treatment of symptoms
  • good communication
  • address spiritual distress
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8
Q

Withholding versus withdrawing treatment

A
  • no reason to differentiate between in western bioethics
  • Withdrawing - act of commission
  • Withholding - act of omission
  • Some cultures have perception that withdrawing less acceptable than withholding.
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9
Q

Difference between withdrawing/withholding and PAS?

A
  • withholding/withdrawing declining treatment that is artificially sustaining life
  • PAS provision of means to end a life prematurely
  • Not the same
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10
Q

Ethical principles of modern bioethics

A
  • Beneficience
  • Non maleficience
  • Autonomy
    • patients do not have right to demand harmful and non beneficial treatments
  • Justice
    • fair use of scarce resources
    • treat the patient in front of you or society as a whole

Proportionality

  • LST should be foregone if it causes more harm than benefit

Futility

  • Not recommended to use as a justification for withholding/withdrawing care
  • no definition of futile
  • judgment of futility is subjective
  • enables clinicians to avoid difficult but beneficial conversations

Non Abandonment

  • physician withdraws from therapeutic relationship without warning or reasonable alternative for care.
  • clear messaging about non abandoning and making plan for next phase and sx management/death.
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11
Q

Principle of Double Effect

A
  • Nature of act must be good or morally neutral
  • Harmful effect must be foreseen but not intended
  • Harmful effect must not be a way of producing good effect
  • Good effect must outweigh bad effect

Morally acceptable

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12
Q

Hemodialysis

A
  • more acceptable to many to withhold dialysis
  • death from uremia not asymptomatic : pain, agitation, myoclonus, muscle twitching, dyspnea, pruritis, nausea
  • discuss symptoms, time to death, place of death, prognosis
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13
Q

Artificial hydration and nutrition

A
  • unlikely to increase life expectancy in patients with advanced disease
  • add to suffering or even decrease life expectancy
    • line sepis, aspiration, diarrhea, hypervolemia, pressure ulcers, pain, local infection, nausea
  • some religions consider AHN to be a basic human right/care not medical treatment
  • Legally AHN (US) is a medical procedure that can be withheld or withdrawn
  • cause of death is the disease that causes inability to eat rather than lack of nutrition itself
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14
Q

Withholding/withdrawing care in severe neurologic impairment

A
  • Persistent vegetative state vs minimally conscious state
  • PVS: not conscious, no pain, no dyspnea
    • focus on family? Patient has no interests
  • MCS: intermittent consciousness and possibility for recovery
    • optimize conditions for recovery
    • attempt to communicate
    • if withdrawing care, do the same way as for non neurologically impaired people
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