Withholding and withdrawal of treatment
See also Breaking Bad News
Based on UHNS guidelines
What is the need of a critically ill patient – survival at all costs or leaving hospital with a reasonable quality of life?
The 4 rules of ethical principles must be applied to both scenarios. For example a patient may want (autonomy) survival at all costs which may conflict with the other 3 rules.
If withholding treatment is not against the patient’s expressed wishes (autonomy) and offers no benefit to the patient (namely it is futile and in all likelihood it constitutes a harm) then it is ethically ok to do so.
This can be rationalised with ventilation: IPPV may involve infections, discomfort, repeated suctioning etc. On the principle of “do no harm” this can be seen to be untenable. Hence death can be considered preferable to suffering without prospect of improvement.
In our resource scarce system, ICU access has to some degree to be restricted to those who would benefit most (distributive justice).
Inevitably this is based on both opinion and evidence and is a complex decision.
Withdrawal decisions are made in consultation with families. This is not just a point of common courtesy. Legally if a family object to withdrawal of treatment the issue can escalate to the courts which may significantly prolong the process.
It is important however to engage the family in the process but to make it clear the decision is a clinical one so as to avoid them feeling responsible for the death of their relative.
Legally the position remains essentially unchanged sine the case of Tony Bland. It has been reiterated in case law and in a recent challenge to the GMC guidance by Lesley Burke. Physicians are not obliged to provide treatment that they feel is inappropriate - even if the patient wishes it (ie conflicts with autonomy). Stopping life sustaining treatment does not constitute manslaughter because it is regarded in law as an omission to continue treatment rather than an act to stop it.
One method of treatment withdrawal is:
Most patients will be sedated when the decision is made. If not, one should consider the need for sedation/analgesia for patient comfort and commence this prior to altering other agents (such as inotropes).
The choice of sedative varies: all are acceptable.
If de novo many consultants will start diamorphine (25 mg in 50 ml @ 1-10 ml/h) or morphine. This is because the respiratory suppressant nature of the agents will ensure comfort when hypoxia and hypercarbia ensue.
Once comfort is ensured the family are typically invited into the area with curtains drawn. The monitor alarms should be silenced and the monitor ideally easily accessible to the ITU staff to ensure minimal disturbance.
Families should be aware that the process may range from very rapid to a number of hours.
Ventilatory support is discontinued in a variety of ways. The choice depends on the quality of spontaneous ventilation.
ETT remains. Patient placed on FiO2 of 0.21 and rate turned down and alarms re-set. Disadvantage that the ventilator will continue after death and will need to be switched off.
ETT remains. Patient disconnected and placed on Swedish nose at ETT with O2 piping attached but no flow. Alternatives such as CPAP circuits or anaesthetic bags can be used but involve some extra fresh gas flow and thus more than “room air”
ETT removed. Patient placed on a face mask with no fresh gas flow or no mask. Consider airway adjunct to minimise airway obstruction and subsequent (patient and relative) distress.
Inotropic/ vasopressor support is discontinued. Stop all medication other than those necessary for comfort.
Opinion on whether nutritional support or fluids should continue varies but is unlikely to be a key issue in ICU withdrawals.
The other caveat on the location is if the patient is being considered for non-heartbeating organ donation
A good resource is the document produced by the Intensive care society.
Organ donation on ICU
The ICU has extensive involvement with the Transplant coordinators and they are very approachable and available for advice. With the advent of non-heart beating donation they have become even more involved.
At present donation is discussed with families at time of Brain Stem Death Testing, either prior to first set or between sets. Changes in legislation give
families less scope to object if the potential donor had previously expressed desire to donate (evidenced by donor card or placement on a national register).
A good resource is the UK transplant website www.uktransplant.org.uk
If a decision is made the patient is for organ donation then a process commences of arranging recipients, coordinating teams, arranging theatres and
anaesthetists and switching the focus of care of the patient (donor) to that of organ preservation.
Advice will be provided by the coordinator