Withdrawing and withholding treatment in intensive care. Part 3. Practical aspects

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.

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.

Withdrawal of life-support treatment: the experience of critical care nurses

Technological advances in health care have made it possible to restore and prolong life for patients who would have died in the past. Unfortunately, one consequence of this is that some patients linger in intensive care units (ICUs), dependent on the technologies but with no hope of recovery. Therefore, decisions regarding withdrawal of life-support treatment are increasingly being faced by the health-care team. This study aimed to explore the lived experience of critical care nurses who had cared for patients during withdrawal of life-support. The methodology employed was interpretive phenomenology. Interviews were conducted with seven critical care nurses, with the meanings of the experience of withdrawal of life-support treatment for these nurses extrapolated from the narratives and clustered into themes. The study highlighted the importance of honest communication during the processes of decision-making and withdrawal of treatment. It was important for these nurses to be sure that family members were well-informed regarding the process of withdrawal of life-support treatment and that they could provide support and ensure that the patient's comfort and dignity were maintained during the process. The need to debrief after the event became evident but formal debriefing processes were rarely undertaken.

International perspectives on ethics in critical care

Differences in culture, resources, demand, level of development, and cultural and religious differences may alter ethical approaches around the world. The principles of medical ethics are beneficence, nonmaleficence, autonomy, disclosure of information, and social justice. Difficult decisions as to whom to admit and whom to exclude are faced by physicians internationally. Differences between countries are seen in the withdrawal and withholding of treatments and in the obtaining of informed consent in emergency circumstances.

Dignified death: a German perspective

After discussing some defining questions concerning dignified death, active and passive euthanasia, assisted suicide and the criteria for free will and informed consent, the juridical situation in Germany is reported. Passive euthanasia according to the patients' free will is accepted, assisted suicide, active euthanasia, and passive euthanasia without informed consent are not accepted. The ethical discussion on these topics in Germany reveals a spectrum of opinions. There is somewhat more emphasis on the cons than on the pros. Humanistic and economic arguments merge in the debate. The philosophy of consequentialistic utilitarianism is heavily criticized by many authors who warn that respect even for the unproductive life must not fade. After some remarks on empirical studies on attitudes towards death and the history of attitudes towards euthanasia the conclusion lists the arguments, pros and cons, and gives a personal view.

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.