1. Withdrawing and withholding treatment at the end of life
The ethics and practice of treatment withdrawal

2. Some guiding principles
Beneficence (doing good)
Non-maleficence (avoiding harm)
Autonomy (respecting the person)
Justice (ensuring fairness to all)

3. Is it ethical to take away treatments that are sustaining life?
Yes, provided that it is
Consistent with patient’s wishes as expressed or documented
and
In the patient’s best interest
Beneficence
Non-maleficence Autonomy
Justice

4. Is withdrawing different from withholding treatment?
Ethically no
If treatment not beneficial, ethical to stop it
If treatment not beneficial, ethical to not start it
Beneficence
Non-maleficence Autonomy
Justice

5. Are we asking the wrong question?
Instead of “can it be in the best interest of the person that treatment is withdrawn?”
Ask “can it be in the best interest of the patient that life should be prolonged by this treatment?”
Beneficence
Non-maleficence Autonomy
Justice

6. Risks and benefits of ICU treatment
Complex
Immediate and delayed
Invisible and visible
Unknown
Hard to predict
Benefits
Aim to return to quality of life and function acceptable to patient, consistent with their goals

7. Reasons for admission to ICU
Reversible illness
Uncertain reversibility (trial of therapy)
Difficult symptom management
Family issues
Consideration for donation

8. Responsibility of the intensivist
Maintaining team integrity
Accountability
Communication
Building relationship with family
Reassessment of progress
Determination of patient wishes
Goal setting
Maintaining physiological stability
Realistic chance of good outcome?
Is this a potential donor? 8

9. Sources of conflict Duty to current patients
Duty to provide care to those who could benefit from it
Duty to use limited resource wisely to avoid compromising healthcare elsewhere in the system
Decisions must be reasonable & accountable
Beneficence
Non-maleficence Autonomy
Justice

10. An aside on cognitive dissonance
Balance between confidence in decision making/diagnosis/treatment and humility to accept might be wrong
Only time will tell: trial of therapy

11. Withdrawal or withholding requires
Reflection on and within practice
Goal setting
Knowledge of what is possible
Knowledge of patient wishes
Reassessment of patient and response
Consensus
Communication and relationship
Courage and accountability

12. Effects
Takes a toll on staff: decision-makers, contributors, observers
Not quick process (though effects may be)
Not an easy option
Effect on family can be immediate/delayed

13. Language Clear Honest Respectful
Takes into account understanding and emotions

14. Language Incredibly important
Want: family then focus on treatments rather than goals
Futile or worth
Doing everything where the alternative is doing nothing

15. An aside on futility Subjective Cannot easily be argued with by family
Negative connotation about the person rather than condition/treatment
Ambiguous

16. Language What would he say if he were in the room with us?
Switch focus from trying to cure, to trying to make him comfortable
We need to allow death to happen: our treatments are getting in the way
It’s becoming more obvious that what we are doing isn’t helping him: the treatments are not working
He is showing us that he isn’t getting better
We will continue doing the things that keep him comfortable and stop doing the things that are not helping or are causing him discomfort

17. Do you want us to do everything?
There is nothing more we can do
This is futile
Value judgments: it’s not worth carrying on in his case because of who he is
We want your permission to turn off the machines

18. This is looking futile ✖ 18

19. ✖
We need to stop treatment: ICU is a valuable resource and someone else needs the bed more 19

20. It’s not worth carrying on✖
It’s not worth carrying on 20

21. ✔
It’s time to stop doing those treatments that aren’t helping any more and focus on those that are keeping Bob comfortable 21

22. Can you help us understand how Bob would look at this and what he would say if he were in the room with us now? ✔ 22

23. Non-critical care experience
Renal: withdrawal of dialysis
Respiratory: withdrawal of O2 or NIV
Incorporating existing AD or Goals of Treatment/Care document

24. What is Advance Care Planning?
Process by which healthcare preferences can be planned and recorded in case
Includes choosing substitute decision maker who can speak for patient in that event

25. How do we withdraw? Planned Comfort a priority
Location in ICU/hospital/home or other

26. Other considerations Cultural differences
Children (patients or family members)

27. Pitfalls of withdrawing
Might make things worse: create a person who survives in condition inconsistent with their wishes
Or disability might be inconsistent with predictions, e.g. post-intended DCD

28. Essentials Consensus that it is the right thing to do
Understanding of what it means
Clarity around method
Clearly understood by patient and/or family
Communication
Beneficence
Non-maleficence
Autonomy
Justice

29. Consensus and shared decision-making
Decision making is shared between those involved
Consensus: everyone supports the decision that has been made, although it might not be what they would prefer
Beneficence
Non-maleficence Autonomy
Justice

30. Sources of conflict

31. Cultural beliefs incongruent with withdrawal
Family disagreement
Emotions preclude discussion and understanding
Staff disagreement
Influence of staff beliefs
What constitutes a good outcome?
Inadequate preparation

32. Support and advice Cultural support Clinical colleagues Second opinion
Legal advice (organisation)

33. Do we really do what we say we do?
Psirides & Sturland Crit Care Resus 2009 Staff response to anonymous WD scenario Retrospective audit 40 patients who had WD

34. Difference between belief and practice
(IV fluid, ECG, pulse oximetry)
Documentation incomplete
Inconsistencies around communication of clear rationale
Reflects challenges of ICU EOLC: symptom assessment in non-verbal, belief that IV fluid beneficial

35. Conclusion (mine)
Increasing the dialogue around EOLC in ICU is essential: role for Palliative Care
Contributions from all members of the team involved in the process
Communication: could do better

36. Developments
Introduction of a guiding tool for EOL improved cessation of treatments and monitoring, documentation
Impact on patient and family experience unknown

37. Are we doing the right thing?
Patient and family perspective: bereavement data
Consistent with professional guidelines and code of ethics
Reflection on practice
Beneficence
Non-maleficence Autonomy
Justice

38. It’s complicated
“EOL decisions are difficult, unsettling and sometimes distressing. Professionals have different views and sometimes reach different conclusions. This is not necessarily a sign we are on the wrong track, and should not be taken to preclude withholding or withdrawing treatment if that is consistent with the patients wishes”
Wilkinson et al Bioethics 2016
Beneficence
Non-maleficence Autonomy
Justice

39. Questions?