Withholding and Withdrawing

Treatment

Dra Frances Avils

Withholding Vs. Withdrawing

Active Vs passive distinction

Conventional wisdom in medicine said withdrawing is harder
than withholding
This has been challenged by modern medical ethicists -
withholding a treatment that has not been tried is morally
harder than withdrawing one that has not proven beneficial

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 Benefits/Burdens Standard

Benefits
health benefits - treatment of disease or symptoms
quality-of-life benefits - improved mental status or physical
comfort
Burdens
increased pain, suffering, debilitation
reduced quality of life

3
 What do we know about patients intensive care
experiences?

There is evidence of significant suffering in ICU patients

with regards to pain, dyspnea, anxiety, sleep disturbance,
depression
A substantial majority of physicians managing ICU care did
not specifically discuss prognosis with families
54% of family representatives did not understand the
diagnosis and prognosis immediately following a
conference with the treating MD
MDs do 75% of the talking in family conferences
4
 Challenges Unique to the
ICU Setting
Often no prior relationship with patient or family
Traditional separation of intensive care/palliative care
Patient often not a participant in discussions
Families unable to participate in high-tech care

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 Advance Directives

The great hope of the 80s and 90s

Do not significantly affect the aggressiveness or cost of ICU care
Do not change decision-making in the ICU
Can be difficult to interpret for a given patient
What is terminal
What is extraordinary means
What is quality of life
Still an important piece of the puzzle
6
 Brain Death

Patient is considered legally dead

Criteria for diagnosis include combination of neurologic physical exam
and testing (apnea test/EEG)
Cardiopulmonary support sometimes continued until family or others
arrive
Conceptually simple, but can be difficult in practice

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 Coma

Relatively short-term (weeks)

Eyes closed, no evidence of wakefulness
No evidence of communication or purposeful movement
Often progresses to PVS

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Vegetative State (formally Persistant VS)

First described in 1972

No evidence of awareness of self or others -
unable to interact
Intermittent sleep-wake cycles
Some preserved cranial and spinal reflexes
No purposeful behavioral responses
Timing and diagnostic parameters are under
debate 9
 Locked-In Syndrome

Patients are awake, alert, with normal cognition (to the

extent that it can be tested)
Often caused by pontine infarction or hemorrhage
Profound quadriplegia, some preserved eye movements
Can be confused with coma or PVS

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Landmark Cases in Futility Ethics

1975 - Karen Ann Quinlan

1983 - Nancy Cruzan

1995 - Hugh Finn

2005 Terri Schiavo

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 Quinlan, 1975

21 yo NJ woman with severe anoxic brain injury after

alcohol/drug overdose
Dx: PVS
Required ventilator and artificial feeding/hydration
Father petitioned to stop vent several months later
Opposed by physicians, backed by local court and State
Attorney General
NJ Supreme Court granted request
KQ died 10 years later 12
 New Jersey Supreme Court in Quinlan,
1975

the States interest (in the preservation of life) weakens

and the individuals right of privacy grows as the degree
of bodily invasion increases and the prognosis dims.
Ultimately, there comes a point at which the individuals
rights overcome the States interest.

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 Cruzan, 1983

25 yo with PVS after MVA

Required artificial feeding and hydration but not ventilator
After 4 years, parents asked that hospital stop tube feedings -
hospital refused
Final decision by U.S. Supreme Court affirmed competent
persons right to refuse any life-sustaining treatment, and for
incapacitated persons, left to the States the issue of whether
legal standard of substituted judgment would be satisfied by
only verbal statements
NC died 1990, 13 days after feeding tube removed

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 Finn, 1995

44 yo television newscaster with PVS after MVA

Wife, sister, and physician wanted feeding tube removed
Finns parents and brothers disagreed
VA Governor James Gilmore intervened to block removal
of tube, citing the States interest in protecting its most
vulnerable citizens
Decision overruled by local and State Supreme Court
Hugh Finn dies 1998 after removal of tube
Court refuses to force State to pay wifes legal fees 15
 Schiavo, 2005

1990 - 27yo woman suffers cardiac arrest

secondary to potassium imbalance, with
subsequent anoxic brain injury and PVS
Husband Michael Schiavo is guardian
Terris parents, the Schindlers, oppose removing
Terris feeding tube
Florida Gov. Jeb Bush intervenes in 2003
Florida House passes Terris Law that allows
one-time stay in certain cases
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Terri Schiavos CT scan

Left image shows brain CT

of a normal 25 year old
Right image shows Terri
Schiavos brain CT at the
time of the debate about
her withdrawal decision
Who opposes withholding and
withdrawing care, and why?

Advocacy groups for persons with

disabilities (NDY)
Right to Life groups
Some religious groups and organizations
 Withdrawing and Withholding
Treatment II The Role of Advance
Care Planning
 Advance Directives

Living wills
Power of Attorney for Healthcare
Healthcare proxy
Appointing a surrogate decision maker is usually
considered the most useful AD
Details and circumstances of clinical situations are
dynamic and often difficult to predict (sometimes)
Legal requirements vary by state, and are
summarized at caringinfo.org
 Advance Care Planning

Getting information on tx options

Deciding on treatment preferences
Getting info on how disease or serious illness
might progress
Discussion w MD about treatment goals, risks,
benefits
Sharing personal values with loved ones
Using AD to put into writing preferences about life-
sustaining treatment specific to the patient
 Problems with AdvanceDirectives

In a survey of almost 5,000 charts:

66% were durable power of attorney
31% were standard living wills or other written
instructions
Only 3% provided additional instructions for medical
care, and even fewer contained specific instructions
about the use of life-sustaining medical treatment
More problems

Legal requirements and restrictions may be

counterproductive
Obtaining witness signatures and notarizing may be
difficult to make happen in a Dr.s office
State hierarchy laws can be inflexible and may not apply
in certain situations
The emphasis should be on the discussion about end of
life care, and not on signing the legal document
Issues to be considered in end-of-life
discussions
Overall attitude towards life
Attitudes about independence and control, and the
loss of them
Religious or spiritual beliefs and moral convictions
Views on health, illness, death and dying
Feelings toward doctors, other caregivers, and
the culture) of modern medical care
Opportunities for discussion about
end-of-life issues
Significant life events marriage, birth, death of
a loved one, retirement, birthdays, etc.
While drawing up a will or other estate/financial
planning
Before and after annual physicals, particularly
when the patient has one or more chronic
conditions
 The role of the physician

Explaining and informing on the illness/disease process

to pt and proxy
Discussion of pain management options
Learning the patients views on quality of life, role of
spirituality/religion
Working out the details of how the plans will be carried out
Education and discussion on hospice and palliative care
Cas2 5: Ethics consult case MR C

53 yo with ESRD, schizophrenia, admitted with shortness of breath

Dxd renal failure, fluid overload, recommend dialysis
Pt refuses dialysis, but wants to be a full code
Pts family wants him to receive dialysis
Ethics consult case Mr C
Pt found to have decisional capacity by psychiatry consult team,
schizophrenia not an issue in this decision
Renal Clinic note found indicating patient did not want dialysis in any
situation, but did want to be full code otherwise
Further discussions with patient revealed he did not want to die
choking for air, but would be DNR if sxs treated
Case 6: Ethics Consult case - CG

69 yo with ALS (amyotrophic lateral sclerosis)

AD appoints daughter as POA for healthcare and
specifies durable DNR
CG plans to die at home with hospice care, but is
in a rehab center for a one week stay to get
mobility equipment and training for family
Falls from his wheelchair, admitted to ED short of
breath, dxd with pneumothorax