Withdrawing and withholding treatment in intensive care. Part 1. Social and ethical dimensions

Legal Aspects of Withdrawal of Therapy

The ability of intensive care to replace or support vital organ function has resulted in some patients surviving for long periods of time without improvement or a terminal event. In patients with no realistic chance of survival, decisions to withdraw or withhold life-sustaining therapies are commonly made.

Withdrawal of life support at the patient's request is lawful at common law and, in some states of Australia, by legal statute. In the intensive care setting though, it is more common for therapy to be withdrawn because the therapy is of no perceived benefit or not in the patient's best interests. However, in Australia there is little case law and very little legislation to direct the decision of whether to withdraw life-sustaining therapy on the grounds of futility or the patient's best interests.

The legislation that does exist in Australia, as well as law from other jurisdictions, largely places responsibility for the decision to withdraw therapy on the doctor in charge of the patient's care. However much weight is frequently placed on the wishes of the family.

Disagreements between family and clinicians over decisions to withdraw therapy are unusual and generally resolve over time. However if disagreement persists, it may be advisable to apply to the courts for a declaratory judgement, given the tenuous legal basis of withdrawal of life-sustaining therapy in Australia and the uncertainty over the courts’ view of the role of the patient's family in the decision-making process.

Intensive care in Australia and New Zealand

This article provides an up-to-date account of intensive care in Australia and New Zealand. Overall, intensive care medicine in Australia and New Zealand is in a healthy state. It began early and has developed into a distinct and strong medical specialty. There are well-developed organizations dealing with all aspects of the specialty. The ICU is recognized as an expensive and limited resource. Overall, intensivists in these two countries have good control of it and have learned to use it wisely.

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.

An insight into Australian nurses’ experience of withdrawal/withholding of treatment in the ICU

BACKGROUND

The success of biotechnology has created moral and ethical dilemmas concerning end-of-life care in the Intensive Care Unit (ICU). Whilst the competent individual has the right to refuse or embrace treatment, ICU patients are rarely able to exercise this right. Thus, decision-making is left to medical professionals and family/significant others.

AIM

This study aimed to explore the lived experience of ICU nurses caring for clients having treatment withdrawn or withheld, and increase awareness and understanding of this experience amongst other health professionals.

METHODS

Van Manens' (1990) phenomenological framework formed the basis of this study as it provided an in-depth insight into the human experience. A convenience sample of ten ICU Nurses participated in the study. Conversations were transcribed verbatim and analysed using a process of thematic analysis.

RESULTS

Five major themes emerged during the analysis. These were: (1) comfort and care, (2) tension and conflict, (3) do no harm, (4) nurse-family relationships and (5) invisibility of grief and suffering.

CONCLUSION

The experience of providing care for the adult having treatment withdrawn or withheld in the ICU represents a significant personal and professional struggle. Improvements in communication between health professionals, debriefing and education about the process of withdrawing or withholding treatment would be beneficial to both staff and families and has the potential to improve patient care and reduce burden on nurses.

Limitation of life support: Frequency and practice in a Hong Kong intensive care unit*

OBJECTIVE

To examine the frequency and the decision-making processes involved in limiting (withdrawing and withholding) life support therapy in critically ill Chinese patients in the intensive care unit.

DESIGN

Prospective survey of patients who had life support limited between April 1997 and March 1999.

SETTING

Medical and surgical intensive care unit of a teaching hospital.

PATIENTS

All patients admitted to the intensive care unit of the Prince of Wales Hospital who subsequently died and/or had life support limited. Brain-dead patients were excluded from analysis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 490 patients who died in the intensive care unit, limitation of life support occurred in 288 (58.8%). Relatives or patients requested limitation of life support in 32 cases (11%). The family and/or patient concurred with limitation of life support in 273 occasions (95%). Therapy was withheld in 30.8% and withdrawn in 28.0% of deaths. Therapy limited included inotropes, additional oxygen, and renal replacement therapy.

CONCLUSIONS

Limitation of therapy in dying Chinese patients occurs frequently in intensive care patients, and both patients and relatives concur with medical decisions to limit therapy in these patients. Withholding therapy rather than withdrawing therapy occurs more frequently than in Western populations.

Attitudes regarding organ donation from non-heart-beating donors

PURPOSE

To determine the attitudes toward organ donation from non-heart-beating cadaver donors in a sample of the general public and health care workers.

MATERIALS AND METHODS

A moderator-administered questionnaire was completed by members of the general public, recruited randomly from a professional consumer research group's database, and health care workers recruited from the same database, family practice clinics, and local hospitals. Two primary scenarios were tested: (1) patient in coma, not going to survive intensive care unit (ICU), and (2) patient lapsing in and out of consciousness, lifetime institutional care.

RESULTS

Sixty members of the general public and 68 health care workers completed the questionnaire. The majority of both groups were aware life support could be withdrawn in Scenario 1, however, significantly fewer were aware life support could also be withdrawn in Scenario 2 (83% general public vs 34% general public, P <.001 and 94% health care workers vs 78% health care workers, P =.012). Uncertainty in prognosis was cited as the primary concern. The issue of organ donation was directly linked with withdrawal of life support. The majority of both groups believed that organ donation would be permissible if further life support were deemed to be not in the patient's best interest because of poor short-term prognosis (94% health care workers and 98% general public for Scenario 1 and 87% health care workers and 81% general public for Scenario 2). The greatest difficulty arose in defining futility of care. Expected quality of life, patient's and family's values, opinions, and religious beliefs were felt to be most important in determining decisions regarding futility and withdrawal of life support. Physician beliefs and values were felt to influence decisions more than they should.

CONCLUSIONS

Both the general public and health care workers support the use of non-heart-beating cadaver donors once a decision has been made to withdraw life support. However, both groups raised concerns regarding how the decision to withdraw life support is made.

ICU Cornestone: a lecture that changed my practice

In 1982, the author attended a lecture by Professor Joseph Civetta dealing with the concept that, at times, the goal of care should be comfort rather than cure, and that inappropriate care prolonged dying and suffering. Efforts to improve end-of-life care subsequent to this had effects on care at a local level and at a state level. Intensive care providers should be leaders in the provision of appropriate and compassionate care at the end of life.

Limitation of life support: frequency and practice in a London and a Cape Town intensive care unit

OBJECTIVES

To examine the frequency of limiting (withdrawing and withholding) therapy in the intensive care unit (ICU), the grounds for limiting therapy, the people involved in the decisions, the way the decisions are implemented and the patient outcome.

DESIGN

Prospective survey. Ethical approval was obtained.

SETTING

ICUs in tertiary centres in London and Cape Town.

PATIENTS

All patients who died or had life support limited.

INTERVENTIONS

Data collection only.

RESULTS

There were 65 deaths out of 945 ICU discharges in London and 45 deaths out of 354 ICU discharges in Cape Town. Therapy was limited in 81.5% and 86.7% respectively (p = 0.6) of patients who died. The mean ages of patients whose therapy was limited were 60.2 years and 51.9 years (p = 0.014) and mean APACHE II scores 18.5 and 22.6 (p = 0.19) respectively. The most common reason for limiting therapy in both centres was multiple organ failure. Both medical and nursing staff were involved in most decisions, which were only implemented once wide consensus had been reached and the families had accepted the situation. Inotropes, ventilation, blood products, and antibiotics were most commonly withdrawn. The mean time from admission to the decision to limit therapy was 11.2 days in London and 9.6 days in Cape Town. The times to outcome (death in all patients) were 13.2 h and 8.1 h respectively.

CONCLUSIONS

Withdrawal of therapy occurred commonly, most often because of multiple organ failure. Wide consensus was reached before a decision was made, and the time to death was generally short.

Resuscitation in cancer. Comparison of patient and health staff preferences

One hundred oncology patients from a major teaching hospital and their treating health staff were studied in the second phase of research examining attitudes towards cardiopulmonary resuscitation (CPR). A descriptive approach was used incorporating semistructured interviews of patients and established questionnaire measures, examining knowledge of and attitude towards disease and treatment, psychological functioning, and current and projected attitude toward resuscitation. Health staff also participated in a semistructured interview. This phase of the project focused particularly on a direct comparison of patient and staff assessments. In current circumstances, 10% of patients refused resuscitation. This was associated with disease of good prognosis. In a future hypothetical deteriorated scenario presented to patients, 39% declined resuscitation. This was associated with a past history of suicidal behavior. In current circumstances, health staff designated 14% of patients "Do-Not-Resuscitate" (DNR)--this was associated with a number of variables considered to predict poor outcome in resuscitation. In the future scenario, staff designated 54% of patients DNR--this was associated again with poor resuscitation outcome variables, but also independently, with a past psychiatric history. Comparison of patient and health staff preferences for resuscitation showed moderate yet significant concordance in current circumstances but not in the future scenario. The findings indicate firstly the feasibility of discussing resuscitation preferences with seriously ill patients and secondly an urgent need to improve patient and staff discussions regarding resuscitation, as staff and patients' attitudes to resuscitation differ.

The significance for critical care nurses of the "dying with dignity" legislation

This paper examines the potential contribution of the critical care nurse to ethical decisions made with respect to the dying with dignity legislation. The literature to date on ethics in nursing has largely focused on increasing nurses awareness thereby encouraging their contribution to the ethical decision-making process. By accentuating the 'art of nursing' where forms of knowing encompass an understanding of the patient's experience, this article describes the unique contribution that the nurse can make to the specific area of 'dying with dignity' in the acute care setting. On a theoretical level this knowledge is invaluable as it ensures a range of constituents are accommodated in this decision-making process, however, in practice this ideal is not readily attainable. Firstly, tradition seeks to curtail the value of this form of nursing knowledge in the decision-making process and secondly, nurses need to recognise their own prejudices in order to make an appropriate contribution to this legitimate body of knowledge.

The usefulness of intensive care treatment: perspectives of medical and nursing staff

Which patients' states or circumstances effect the judgement of Intensive Care specialist (IC) medical and nursing staff as to how useful intensive care treatment is? Do IC medical and nursing staff differ significantly in their attitudes regarding the usefulness of IC treatment? Or do they show similarity in their attitude but differ as a group from broader community views of the usefulness of IC treatment? To gain insight into these questions a group of IC staff (35 medical, 108 nursing) and pre-clinical students (110 medical, 136 nursing) responded to a questionnaire asking them to consider how 12 patient factors including age, functional state, socioeconomic factors, length and cost of the IC stay, culpability, disease state and length of survival after IC unit discharge effected their judgement of the usefulness of IC treatment for an individual patient. Results indicated that: (i) medical and nursing students felt IC treatment more useful than IC staff regardless of the patient characteristic; (ii) IC doctor and nurse responses were very similar; (iii) IC staff considered that IC treatment "tended to be useless" or was "useless" if the patient had required "institutional care", was in a "vegetative" state before or after IC treatment, belonged to the pathology groups of "malignancy" and "diseases of ageing", belonged to the diagnostic groups "AIDS" and "quadriplegia", or where survival post discharge from IC was expected to be "< 3 months"; and (iv) cost and length of stay in IC were not factors that negatively effected any groups perception of the usefulness of IC treatment.

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.

Withdrawing life-sustaining treatment from severely brain-damaged persons

Ventilator support is commonly withdrawn from unconscious patients who cannot breathe when it is reasonably certain that their condition is permanent and further medical treatment is futile. However, there is no consistent practice with permanently unconscious patients who can breathe but cannot swallow, despite the fact that ongoing treatment of these patients is similarly futile. In both groups of patients, the withdrawal of treatment is not euthanasia, and the cause of death is properly considered to be the underlying illness. A review of the medical, legal and ethical literature shows that there is much disagreement about when and how to withdraw tube feeding from patients with severe brain damage. Criteria for withdrawal of treatment should include the permanent unconsciousness of the patient, the permanent absence of a life-sustaining function, the elapse of sufficient time to be certain about the prognosis, the concurrence of at least one independent and qualified medical specialist, and the informed consent of the patient's family or other legally qualified agents.