The patient or surrogate and the health care team cannot reach agreement about a decision to withhold or withdraw life-sustaining treatment. There is no surrogate available and willing to make decisions on behalf of a patient who does not have decision-making capacity or no surrogate can be identified.
Full Answer
Is withdrawal of treatment ethical in critical care?
Withdrawal of treatment is a common practice in critical care settings, perticularly when treatment is considered futile. The case study demonstrates an ethical dilemma, in which Danny is unlikely to make a functional recovery because of multiple organ dysfunction syndromes.
Should medical staff respect patients’ decisions to withdraw treatment?
If his family is involved in the discussion, the medical staff should balance the ethical principles when they make the decision and allocate reasonable resources for patients. In Danny’s case, health professionals opted to respect his decision to withdraw treatment.
Who should make the decisions about patient autonomy and withdrawal?
Romayne claimed that care should make patients feel comfortable and peaceful [ 8 ]. Medical staff members and families should respect patients' autonomy and balance the withholding and withdrawal of treatment. The aims of this study are to discuss who would make the decisions and promote safe ethical practice.
What are Danny's rights to withdraw treatment?
In Danny's case, if he decides to withdraw treatment, then neither the health care providers nor his family can deny his decision. Only Danny has the right to self-determination, decide whether to accept nursing care or refuse to receive information, suggestions or assistance. Consequently, nurses must respect his personal decisions.
Who decides in withdrawal of treatment in a critical care setting?
Ethical decision-making: The best ethical decision is Danny can decide whether to withhold or withdraw life-sustaining treatment. If his family is involved in the discussion, the medical staff should balance the ethical principles when they make the decision and allocate reasonable resources for patients.
Which concept of moral guidelines focuses on the decision to provide or forgo treatment?
The principle of patient autonomy requires that physicians respect the decision to forgo life-sustaining treatment of a patient who possesses decision-making capacity.
When do you decide to withdraw from life support?
It is best when all the patient's loved ones can agree on whether to withhold or withdraw life support. When the medical situation clearly points in a certain direction, this is more likely. If a unanimous decision can't be made, it may be helpful to try mediation.
What is withdraw treatment?
Withdrawal of therapy is relatively easily defined as the removal of a therapy that was started in an attempt to sustain life but has become futile and is just prolonging the dying process. Withdrawal usually concerns therapies such as mechanical ventilation and administration of vasoactive agents.
Who makes decisions regarding withholding or withdrawing treatment?
When facing decisions about withholding or withdrawing life- sustaining treatment the physician should: Review with the patient the individual's advance directive, if there is one. Otherwise, elicit the patient's values, goals for care, and treatment preferences.
What are four ethical considerations when dealing with a critically ill person?
Abstract. Care of critically ill patients, as in any other field, demands the exercise of ethical principles related to respect of patient's autonomy, beneficence, nonmaleficence, and distributive justice.
Is withdrawal of treatment ethical?
The withdrawal of treatment is one of the most emotionally challenging and ethically complex aspects of end-of-life care. As our ability to prolong life progresses, the necessity to address issues such as the withdrawal of treatment increases in parallel.
Who can make life support decisions?
A POWER OF ATTORNEY FOR HEALTH CARE lets you name an agent to make decisions for you. Your agent can make most medical decisions – not just those about life sustaining treatment – when you can't speak for yourself.
When is it justifiable to discontinue life sustaining treatment?
When is it justifiable to discontinue life-sustaining treatments? If the patient has the ability to make decisions, fully understands the consequences of their decision, and states they no longer want a treatment, it is justifiable to withdraw the treatment.
Is Withdrawing treatment legal?
In the United States, the withholding and withdrawal of life support is legally justified primarily by the principles of informed consent and informed refusal, both of which have strong roots in the common law.
What does it mean to withdraw care from a patient?
Broadly speaking, “withdrawal of care” is used by healthcare personnel to refer to the discontinuation of life-prolonging treatments, such as a ventilator, dialysis, vasopressor medications, extracorporeal bypass, artificial nutrition, and others.
What is meant by a patient refusing or withdrawing treatment?
A decision to withhold or withdraw life- sustaining treatment is a common feature of medical practice when caring for people who are approaching the end of life. 2. A person who has capacity can lawfully refuse treatment even if that treatment is needed to keep them alive. Such a refusal should be followed.
What was Danny's decision to withdraw treatment?
In Danny’s case, health professionals opted to respect his decision to withdraw treatment. The medical staff maintained an effective communication with the family involved, and provided the appropriate intervention to collaborate with other health care professionals to perfect further care.
Why is the withdrawal of a ventilator a utilitarian choice?
In Danny's case, the withdrawal of a ventilator is a utilitarianism choice because the limited resource can save more lives and reduce the morality of the medical organisation.
What is non-maleficence in healthcare?
Non-maleficence refers to actions that do not bring harm to patients and others [ 10 ]. Health care providers aim to practice this ethical principle and hold it foremost in their practice. However, a disparity in perspective may exist in many medical therapies [ 14 ]. For example, ventilated treatment, CPR and prolonging and withdrawal of treatment rapidly may be harmful to patients. To reduce the risk of harm to patients, health care providers should consider the former's condition and likely prognosis. Meanwhile, this information should be communicated with patients and their relatives. The Queensland government [ 5] stated that the unwillingness to withhold or withdraw life sustaining measures may also cause harm because patients lack the ability to adapt to the invasive treatment or aggressive therapy. In the current case, Danny was diagnosed with COPD and prostatic cancer over the course of 10 years. Accordingly, his dependence on ventilated treatment has prevented him from having a quality life. Although a mechanical ventilator and antibiotic therapy were effective in maintaining Danny's breathing, such treatment could not prevent the progress of multiple organ dysfunction. Danny told his wife that he felt pain and experienced difficulty in breathing even when he received sedation medications. Evidently, the continuous prolonging of the process has caused physical and mental suffering. The patient had expressed these views because he regarded the intervention as harmful. His wish must also be considered in the decision-making process. In relation to this issue, the following questions must be answered: Should healthcare professionals respect patient choices without question? What is the role of professional responsibilities in this issue? The concept of justice can provide the answer to these questions.
What is the best ethical decision?
Ethical decision-making. The best ethical decision is Danny can decide whether to withhold or withdraw life-sustaining treatment. If his family is involved in the discussion, the medical staff should balance the ethical principles when they make the decision and allocate reasonable resources for patients.
Why is Danny unlikely to make a functional recovery?
The case study demonstrates an ethical dilemma, in which Danny is unlikely to make a functional recovery because of multiple organ dysfunction syndromes. Under such a circumstance, withdrawal of treatment will inevitably be considered, although his family refused to do so.
Is withdrawal of treatment a decision making process?
Withdrawal of treatment is a complex decision-making process. In such a circumstance, a patient's autonomy is critical in decision-making. The general principles of law and medical practice indicate that people have a right to decide.
Can withdrawal of treatment lead to death?
In critical settings, the withdrawal of treatment may lead to patients dying immediately, whilst a few patients will opt to leave the hospital. All interventions should be individualised to the needs of the patients and their families.
What is treatment withdrawal in the ICU?
Treatment withdrawal in the ICU involves a number of ethical considerations. Often patients are too obtunded and lack capacity—either as a result of sedative medications or as a consequence of the underlying disease process—to engage in any meaningful discussions about treatment withdrawal. The patient’s wishes in such circumstances are often unknown, and the burden of decision-making usually falls to the ICU multidisciplinary team (MDT). The General Medical Council (GMC) released specific end-of-life guidance in 2010, 4 which outlines the ethical principles that are helpful when attempting to navigate these difficult situations.
What is the role of the clinician in determining if a patient's capacity is impaired?
If the patient’s capacity is impaired, it is the clinician’s duty to provide the patient with all the necessary help and support to maximize their ability to understand, retain, and use the information provided to reach a decision.
What should an ICU MDT do?
The ICU MDT should be educated on acute bereavement support. Grieving families should also be offered ongoing referrals to community bereavement services, and every ICU should ideally have a list of suitable resources that the family can access for support during and after the period of treatment withdrawal. If requested, the family should be offered a future appointment to return to the ICU and debrief about the withdrawal process with a member of the ICU MDT. Formal debrief sessions should also be available for members of the ICU MDT after particularly difficult or emotionally charged cases.
What is palliative care?
The World Health Organization definition of palliative care is ‘an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification, impeccable assessment and treatment of pain and other physical, psychosocial and spiritual distress’. 19 The specialist palliative care team is therefore a valuable resource in the management of terminally ill patients in critical care. Particular areas of expertise that can be integrated into the critical care management of the dying patient include: 20
What is shared decision making?
14 A shared decision is defined as one where ‘responsibility for decisions is shared jointly by the treating physician and the patient’s family’. 14 Despite this, large international differences still exist regarding the extent of family involvement in end-of-life decisions and encountering a family who do not wish to be involved in these decisions, while increasingly uncommon, can still happen. Figure 1 outlines the steps in the shared decision-making model, whereas Figure 2 illustrates best practice for MDT family communication.
What is the right of patients at the end of life?
Patients who are approaching the end of life deserve the same quality of care as all other patients and must be treated with dignity, respect, and compassion. They still have a right to the privacy and confidentiality afforded to any patient receiving active treatment.
What is the GMC guidance for ICU?
In the context of ICU treatments, it is likely that the patient will not have the necessary capacity to make a decision regarding ongoing management. Treatment decisions will therefore fall to the responsible clinician, and the GMC guidance outlines a clear stepwise approach to be used in these circumstances.
When should a physician elicit patient goals of care?
Physicians should elicit patient goals of care and preferences regarding life-sustaining interventions early in the course of care, including the patient’s surrogate in that discussion whenever possible.
Is there an ethical difference between withholding and withdrawing treatment?
While there may be an emotional difference between not initiating an intervention at all and discontinuing it later in the course of care, there is no ethical difference between withholding and withdrawing treatment.
Can a surrogate make decisions on behalf of a patient?
There is no surrogate available and willing to make decisions on behalf of a patient who does not have decision-making capacity or no surrogate can be identified. In the physician’s best professional judgment ...
Is it ethical to withhold life sustaining interventions?
Decisions to withhold or withdraw life-sustaining interventions can be ethically and emotionally challenging to all involved. However, a patient who has decision-making capacity appropriate to the decision at hand has the right to decline any medical intervention or ask that an intervention be stopped, even when that decision is expected to lead ...