Intensivists managing end-of-life care: dwarfs without giants' shoulders to stand upon

A few realistic questions raised by organ retrieval in the intensive care unit

Organ transplantation saves the lives of many persons who would otherwise die from end-stage organ disease. The increasing demand for donated organs has led to a renewed interest in donation after circulatory determination of death (CDD). In many countries (including France), terminally ill patients who die of circulatory arrest after a planned withdrawal of life support may be considered as organ donors under certain conditions. While having equal responsibility towards the potential donor and the persons awaiting a transplant, caregivers may experience an ethical dilemma between the responsibility to deliver the best care to the dying, and the need to retrieve the organs. Once it has been established that the patient wishes to be a donor, we assume that end-of-life care and organ donation may have convergent goals when they contribute to transforming a comfortable death into a chance of life for others in need.

Withholding or withdrawal of treatment under French rules: a study performed in 43 intensive care units

Background

In France, decisions to limit treatment fall under the Leonetti law adopted in 2005. Leading figures from the French world of politics, science, and justice recently claimed for amendments to the law, considering it incomplete. This study, conducted before any legislative change, aimed to investigate the procedural aspects of withholding/withdrawing treatment in French ICUs and their adequacy with the existing law.

Methods

The characteristics of patients qualified for a withholding/withdrawal procedure were prospectively collected in 43 French ICUs. The study period (60 or 90 days under normal operating conditions) took place in the first half of 2013.

Results

During the study period, 777 (14 %) of 5589 admitted patients and 584 (52 %) of 1132 patients dying in the ICU had their treatment withheld or withdrawn. Whereas 344 patients had treatment(s) withheld (i.e., not started or not increased if already engaged), 433 had one or more treatment(s) withdrawn. Withdrawal of treatment was applied in 156 of 223 (70 %) brain-injured patients, compared to 277 of 554 (50 %) patients with other reasons for admission (p < 0.01). At the time of the decision-making, the patient’s wishes were known in 181 (23 %) of the 777 cases in one or more different way(s): 73 (9.4 %) from the patient, 10 (1.3 %) by advance directives, 10 (1.3 %) through a designated trusted person, and 108 (13.9 %) reported by the family or close relatives. An external consultant was involved in less than half of all decisions (356 of 777, 46 %). Of the 777 patients qualified for a withholding/withdrawal procedure, 133 (17 %) were discharged alive from the hospital (126 after withholding, 7 after withdrawal).

Conclusions

More than half of deaths in the study population occurred after a decision to withhold or withdraw treatment. Among patients under withholding/withdrawal procedures, brain-injured subjects were more likely to undergo a withdrawal procedure. The prevalence of advance directives and designated trusted persons was low. Because patients’ preferences were unknown in more than three quarters of cases, decisions remained primarily based on medical judgment. Limitations, especially withholding of treatment, did not preclude survival and hospital discharge.

Ethical challenges with deactivation of durable mechanical circulatory support at the end of life: left ventricular assist devices and total artificial hearts

Left ventricular assist devices (LVADs) and total artificial hearts (TAHs) are surgically implanted as permanent treatment of unrecoverable heart failure. Both LVADs and TAHs are durable mechanical circulatory support (MCS) devices that can prolong patient survival but also alter end-of-life trajectory. The permissibility of discontinuing assisted circulation is controversial because device deactivation is a life-ending intervention. Durable MCS is intended to successfully replace native physiological functions in heart disease. We posit that the presence of new lethal pathophysiology (ie, a self-perpetuating cascade of abnormal physiological processes causing death) is a central element in evaluating the permissibility of deactivating an LVAD or a TAH. Consensual discontinuation of durable MCS is equivalent with allowing natural death when there is an onset of new lethal pathophysiology that is unrelated to the physiological functions replaced by an LVAD or a TAH. Examples of such lethal conditions include irreversible coma, circulatory shock, overwhelming infections, multiple organ failure, refractory hypoxia, or catastrophic device failure. In all other situations, deactivating the LVAD/TAH is itself the lethal pathophysiology and the proximate cause of death. We postulate that the onset of new lethal pathophysiology is the determinant factor in judging the permissibility of the life-ending discontinuation of a durable MCS.

End-of-life discontinuation of destination therapy with cardiac and ventilatory support medical devices: physician-assisted death or allowing the patient to die?

BACKGROUND

Bioethics and law distinguish between the practices of "physician-assisted death" and "allowing the patient to die."

DISCUSSION

Advances in biotechnology have allowed medical devices to be used as destination therapy that are designed for the permanent support of cardiac function and/or respiration after irreversible loss of these spontaneous vital functions. For permanent support of cardiac function, single ventricle or biventricular mechanical assist devices and total artificial hearts are implanted in the body. Mechanical ventilators extrinsic to the body are used for permanent support of respiration. Clinical studies have shown that destination therapy with ventricular assist devices improves patient survival compared to medical management, but at the cost of a substantial alteration in end-of-life trajectories. The moral and legal assessment of the appropriateness and permissibility of complying with a patient's request to electively discontinue destination therapy in a life-terminating act in non-futile situations has generated controversy. Some argue that complying with this request is ethically justified because patients have the right to request withdrawal of unwanted treatment and be allowed to die of preexisting disease. Other commentators reject the argument that acceding to an elective request for death by discontinuing destination therapy is 'allowing a patient to die' because of serious flaws in interpreting the intention, causation, and moral responsibility of the ensuing death.

SUMMARY

Destination therapy with cardiac and/or ventilatory medical devices replaces native physiological functions and successfully treats a preexisting disease. We posit that discontinuing cardiac and/or ventilatory support at the request of a patient or surrogate can be viewed as allowing the patient to die if--and only if--concurrent lethal pathophysiological conditions are present that are unrelated to those functions already supported by medical devices in destination therapy. In all other cases, compliance with a patient's request constitutes physician-assisted death because of the pathophysiology induced by the turning off of these medical devices, as well as the intention, causation, and moral responsibility of the ensuing death. The distinction between allowing the patient to die and physician-assisted death is pivotal to the moral and legal status of elective requests for death by discontinuing destination cardiac and/or ventilatory medical devices in patients who are not imminently dying. This distinction also represents essential information that must be disclosed to patients and surrogates in advance of consent to this type of therapy.