Withholding and withdrawing life sustaining treatment Flashcards
1
Q
Approach to decision making
A
- Consider legal and ethical framework
- Assess consequences to using or forgoing life sustaining treatment in given situation
- Assess patient’s decision making capacity
- Make a decision re: life sustaining treatment
- If decision to withhold or withdraw LST is made, make a treatment plan for symptoms and support.
2
Q
- Consider the legal and ethical framework
A
- Is it legal in my jurisdiction?
- what are the ethical principles relevant to a decision ?
3
Q
- 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?
4
Q
- 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?
5
Q
- 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?
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
7
Q
- 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
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.
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
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.
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
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
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
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