Hospital guidelines for deciding about life-sustaining treatment: dealing with health "limbo"

Decision tools for life support: a review and policy analysis

OBJECTIVE

To identify, describe, and compare published documents intended to guide decisions about the administration, withholding, or withdrawal of life support in critical care.

DESIGN

Review article. SETTING AND SOURCES: Publicly available, English-language guidelines or decision tools for life support, identified through systematic literature search.

MEASUREMENTS AND MAIN RESULTS

Forty-nine documents were included and coded for authorship, source, development methodology, format, and positions taken on 12 common life-support issues. Sources were independent academics (n=21, 43%), professional organizations (n=19, 44%), and provider organizations. Eighteen documents (37%) described no development method. Twenty-three (47%) were produced collectively (e.g., by committees or consensus conference), 7 (14%) mentioned a literature review, and 2 (4%) were based upon the author's professional experience. Tools differed in format and focus; we characterize three types as decision schemas (involving clinical practice algorithms; n=7, 14%), decision guides (reviewing legal or professional positions; n=29, 59%), and decision counsels (more discursive and focusing typically on ethical issues; n=13, 27%). Tools addressed 12 common life-support issues: advance directives (67%), resource considerations (51%), ICU discharge criteria (27%), ICU admission criteria (16%), whether withholding differs from withdrawing life support (59%), whether nutrition and hydration decisions are different from decisions about other types of life support (61%), euthanasia (49%), double effect (47%), brain death (35%), special considerations for patients in a persistent vegetative state (51%), potential organ donors (12%), and pregnant patients (10%). Positions on these key life-support issues varied.

CONCLUSIONS

Published tools for guiding life-support decisions vary widely in their genesis, authorship, format, focus, and practicality. They also differ in their attention to, and positions on, key life-support dilemmas. Future research on decision tools should focus on how users interpret and apply the messages in these tools and their impacts on practice, quality of care, participant experiences, and outcomes.

Life-sustaining treatment decisions in Portuguese intensive care units: a national survey of intensive care physicians

Introduction

The objective of the present study was to evaluate the opinion of Portuguese intensive care physicians regarding 'do-not-resuscitate' (DNR) orders and decisions to withhold/withdraw treatment.

Methods

A questionnaire was sent to all physicians working on a full-time basis in all intensive care units (ICUs) registered with the Portuguese Intensive Care Society.

Results

A total of 266 questionnaires were sent and 175 (66%) were returned. Physicians from 79% of the ICUs participated. All participants stated that DNR orders are applied in their units, and 98.3% stated that decisions to withhold treatment and 95.4% stated that decisions to withdraw treatment are also applied. About three quarters indicated that only the medical group makes these decisions. Fewer than 15% of the responders stated that they involve nurses, 9% involve patients and fewer than 11% involve patients' relatives in end-of-life decisions. Physicians with more than 10 years of clinical experience more frequently indicated that they involve nurses in these decisions (P < 0.05), and agnostic/atheist doctors more frequently involve patients' relatives in decisions to withhold/withdraw treatment (P < 0.05). When asked about who they thought should be involved, more than 26% indicated nurses, more than 35% indicated the patient and more than 25% indicated patients' relatives. More experienced doctors more frequently felt that nurses should be involved (P < 0.05), and male doctors more frequently stated that patients' relatives should be involved in DNR orders (P < 0.05). When a decision to withdraw treatment is made, 76.8% of 151 respondents indicated that they would initiate palliative care; no respondent indicated that they would administer drugs to accelerate the expected outcome.

Conclusion

The probability of survival from the acute episode and patients' wishes were the most important criteria influencing end-of-life decisions. These decisions are made only by the medical group in most of the responding ICUs, with little input from nursing staff, patients, or patients' relatives, although many respondents expressed a wish to involve them more in this process. Sex, experience and religious beliefs of the respondents influences the way in which these decisions are made.

Required reconsideration of "do-not-resuscitate" orders in the operating room and certain other treatment settings

It is time to change the assumption that DNR orders apply in every treatment setting in the hospital. It is appropriate to mandate not only that these orders be reconsidered on the basis of time, but also on the basis of setting. When patients enter treatment settings in which discrete, time-limited therapies that can precipitate cardiac arrest are offered, they or their surrogates should reconsider the question of resuscitation with their current and primary physicians. While this will make patient transition from one hospital setting to another more complicated, it will allow patients to receive treatment directed toward their individual needs, immediate treatment objectives, and long-term treatment goals. It will also assure health care professionals that they will not be required to withhold treatment essential for meeting patients' treatment objectives in these settings.

Trying not to talk forever: a tool for change

George Annas’ review finds most of what is in the Hastings Center’s Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying “solid.” He takes no issue with the major substantive points. The fundamental premise of the book—that patients’ interests must be protected and their decision-making authority defended—is a view Professor Annas has long championed as well.

Despite this basic agreement, Annas’ criticisms would be significant ones if the Guidelines were what he presents them to be. But they clearly are not. As the Guidelines themselves state: These are ethics guidelines; they are not legal guidelines. They are an attempt to offer practical and reasonably concise suggestions for how to make decisions; they are no substitute for the literature on the pros and cons of different approaches to the termination of treatment. They are meant to provoke a necessary process of debate within a health care institution; they are not the final moral truth.

The Quinlan case revisited: a history of the cultural politics of medicine and the law

This article explores the cultural politics of medicine and the law through a historical examination of the case of Karen Ann Quinlan. In viewing the Quinlan case as, in part, an unanticipated consequence of the 1968 redefinition of death, this article implicates the importance of historical perspective and methodology in examining the nuances of the cultural negotiation of professional power. Using popular, legal, medical, and bioethics sources in historical context, it reveals how the legal process can nurture misconceptions about medical practice and the role of technology. It also sheds light on how the search for legal protection can motivate medical behavior. In so doing, it challenges the view that Quinlan was an important gain for patients' rights. Instead it views Quinlan's chief legacy as its offer to the medical profession of freedom from criminal prosecution when removing life support from patients in a chronically vegetative state.

The Quinlan case revisited

... The point is that although physicians and hospitals (and their legal counsel) certainly feared in the 1970s and still fear prosecution and civil liability (and perhaps to an unreasonable degree), neither the complex psychosocial and economic nor the equally complex philosophical questions surrounding stopping artificial life support were settled at the time of the Quinlan case, and they are still not settled today. Perhaps our legal history does not need to be revised all that much.

Contributions of empirical research to medical ethics

Empirical research pertaining to cardiopulmonary resuscitation (CPR), clinician behaviors related to do-not-resuscitate (DNR) orders and substituted judgment suggests potential contributions to medical ethics. Research quantifying the likelihood of surviving CPR points to the need for further philosophical analysis of the limitations of the patient autonomy in decision making, the nature and definition of medical futility, and the relationship between futility and professional standards. Research on DNR orders has identified barriers to the goal of patient involvement in these life and death discussions. The initial data on surrogate decision making also points to the need for a reexamination of the moral basis for substituted judgment, the moral authority of proxy decision making and the second-order status of the best interests standard. These examples of empirical research suggest that an interplay between empirical research, ethical analysis and policy development may represent a new form of interdisciplinary scholarship to improve clinical medicine.

Active management of the dying patient

OBJECTIVE

To document the process of managing the dying patient in the intensive care unit (ICU) and thus to broaden community debate about an issue that is usually only discussed at a theoretical or philosophical level.

SETTING

A six-bed ICU in Liverpool Hospital, a 419-bed teaching institution in the southwestern area of Sydney.

PATIENTS

Twenty-seven patients, seen over a nine-month period, who had curative treatment withdrawn or withheld. The mean age of the patients was 68 years and the severity of illness, by the APACHE II scoring system, ranged from 12 to 45.

INTERVENTIONS

Twenty-three of the 27 patients were mechanically ventilated and 11 were receiving inotropic support. Medical staff usually initiated discussions and sought staff consensus that the patient should be allowed to die (on 23 of 27 occasions). Most relatives (25 of 27) accepted this decision. Support therapies and routine care were stopped according to policy guidelines. Sedatives and narcotics were used in some patients (18 of 27). Twenty-one patients died in the ICU and six in the general ward areas.

CONCLUSION

Introduction of a policy to guide management of dying patients in intensive care has been accepted by staff. Most dying patients are now managed in accordance with these guidelines. Further discussion and debate of this important issue, by health professionals and society as a whole, is required.

Decisions near the end of life: professional views on life-sustaining treatments

OBJECTIVES

How do health care professionals assess the care of hospital patients near the end of life? Are physicians and nurses aware of and in agreement with national recommendations regarding patients' rights to forgo life-sustaining medical treatments and to receive adequate pain control?

METHODS

We surveyed 687 physicians and 759 nurses in 5 hospitals.

RESULTS

Almost half (47%) of all respondents and fully 70% of the house officers reported that they had acted against their conscience in providing care to the terminally ill. Four times as many respondents were concerned about the provision of overly burdensome treatment than about undertreatment.

CONCLUSIONS

In summary, many physicians and nurses were disturbed by the degree to which technological solutions influence care during the final days of a terminal illness and by the undertreatment of pain. However, changes in the care of dying patients may not have kept pace with national recommendations, in part because many physicians and nurses disagreed with and may have been unaware of some key guidelines, such as the permissibility of withdrawing treatments.

The negotiation of death: clinical decision making at the end of life

The ability of medical science to prolong biological life through the use of technology raises the question of how far physicians should go in treating the terminally ill patient. In clinical decision making involving the dying patient, physicians, patients and families bring various perceptions and interpretations to the situation. These different realities must be negotiated in order to define the meaning of the situation and the meaning of various medical technologies. The patient's demise becomes a negotiated death, a bargaining over how far medical technology should go in prolonging life or in prolonging death. A case study of the process of ethical decision making in the foregoing of life-supporting therapy in an intensive care setting is presented and analyzed. The decision making process in this case follows a 'cascade' pattern rather than a controlled, reflective model. While ethicists view the withholding and withdrawing of life-supporting treatment as morally equivalent, physicians tend to make a distinction based on the perceived locus of moral responsibility for the patient's death. In the author's interpretation the moral responsibility for the patient's death by withdrawing treatment is shared with family members, while the moral responsibility for the patient's death by withholding treatment is displaced to the patient. The author suggests that an illusion of choice in medical decision making, as offered by the physician, begins a negotiation of meanings that allows a sharing of moral responsibility for medical failure and its eventual acceptance by patient, family and physician alike.