Principles and practice of withdrawing life-sustaining treatments Gordon D. Rubenfeld, MD MSc
Harborview Medical Center, Division of Pulmonary and Critical Care Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104-2499, USA
Most deaths in intensive care units occur after decisions to limit or withdraw life support [1,2]. Despite an extensive literature on whether to withdraw life support, little attention has been given to how to withdraw it [3,4]. For example, a recent edition of a critical care textbook exhaustively covers the ethical and legal aspects of life-support withdrawal, but makes no recommendations for carrying it out . Only recently, in the wake of growing data that problems may exist in providing palliative care in the intensive care unit (ICU), has attention been directed to the practical aspects of withdrawing life support [6 –8]. Many practical questions about withdrawal of life support, and specifically about the withdrawal of mechanical ventilation, are perplexing and controversial: Should the endotracheal tube be left in place? Should the ventilator be weaned slowly or quickly? When and how should sedation be increased? How can the concerns about relieving suffering be reconciled with fears of killing the patient? Should neuromuscular blockade be discontinued? These questions are important because clinicians face them frequently and are still confused by the goals and process of withdrawing life support, and because patients who die after withdrawal of life support may receive inadequate pain and symptom management [9,10].
Principles of withdrawing mechanical ventilation In this era of evidence-based medicine, there is a lack of data to direct clinicians in the optimal management of the dying critically ill patient. Despite the lack of data on optimal management of some aspects of withdrawing lifesustaining treatment, a general consensus exists on the ethical and clinical principles that should guide this care. These six principles are listed in Box 1 [11 – 13].
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G.D. Rubenfeld / Crit Care Clin 20 (2004) 435–451
Box 1. Principles of withdrawing life support 1) The goal of withdrawing life-sustaining treatments is to remove treatments that are no longer desired or do not provide comfort to the patient. 2) Withholding life-sustaining treatments is morally and legally equivalent to withdrawing them. 3) Actions whose sole goal is to hasten death are morally and legally problematic. 4) Any treatment can be withheld or withdrawn. 5) Withdrawal of life-sustaining treatment is a medical procedure. 6) Corollary to 1 and 2: when circumstances justify withholding one indicated life-sustaining treatment, strong consideration should be given to withdrawing all current life-sustaining treatments.
Understanding that the goal of withdrawing life-sustaining treatments is to remove unwanted treatments rather than to hasten death is essential in clarifying the distinction between active euthanasia (providing drugs or toxins that hasten death) and death that accompanies the withdrawal of life support in the ICU. Ethicists draw a line between withdrawing life-sustaining treatments when the expected but unintended effect is to hasten death and providing a treatment with the sole intent of hastening death. Despite the well-established principle that ‘‘withholding and withdrawing are equivalent’’ some clinicians find it difficult to stop treatments that are currently being provided and choose to withhold future treatments while continuing current levels of support. Frequently, clinicians are faced with multiple decisions about a variety of current or potential life-sustaining treatments. For example, consider a patient with respiratory failure, shock, and worsening acidosis with anuria. A family...