1. Ethics in Critical Care Medicine: Withdrawal and withholding treatment
Dr Lau Chun Wing
ICU, Dept of Anaesthesia, PYNEH
Division of Respiratory and Critical Care Medicine, Dept of Medicine, PYNEH
July 2005

2. Withholding and Withdrawal of treatment
Legally no difference between not initiating treatment and withdrawing it
Common practice world-wide to withdraw life support from a terminally ill patient incapable of giving consent under certain circumstances
Generally considered to be ethically and legally distinct from assisted suicide and active euthanasia

3. Mutiple issues to consider
Medical
Ethical
Social
Cultural
Legal
Economic

4. Four basic ethical principles
The principle of beneficence
Kindness, goodness, doing of good
The principle of non-maleficence
Non-(act of doing evil, harmfulness), do no harm
The principle of justice
Respect for patients’ autonomy

5. Medical futility American Thoracic Society
The purpose of life support is not to prolong biological life without qualification; rather it is to sustain or restore a meaningful survival, where “meaningful” refers to a survival that can be valued and appreciated by the patient. Thus, life support is futile for patients who are irreversibly unconscious, and for those who cannot improve from a state of total dependence on intensive medical care and heavy sedation.

6. Criteria of medical futility
The disease process must be terminal
The disease process must be irreversible
Death must be imminent
All reasonable efforts have been made to extend the life of the patient
There has been no objection to withdrawal of life support by attending medical and nursing/paramedical staff and by the patient’s relatives.
Lack of a clear definition of medical futility. The definition has become increasingly elusive as technology has pushed back the limits of what can be done to prolong both life and the process of dying, e.g. the recent Terri Schiavo case

7. Reasonableness
The resonableness of the efforts made by the doctor to preserve life must be judged on all surrounding circumstances, including resources available, demand for resources, and the prognosis of the patient.
Appropriate documentation should be made

8. Do not resuscitate orders
Active conservative management
Conservative management

9. Recommended clinical pathway for the determination of medical futility

10. Communication
Non-verbal communication always speaks louder than words

11. Empathy
Anxiety and sadness: “you seem to be too anxious” vs “sounds like you’re pretty fearful about what this all might mean”
Understanding: “you have not listened carefully to understand what I mean”; “Let mean explain to you again in greater details what the situation is”
Anger: “Don’t be so angry first. Just chill out, if you are so angry you won’t understand what I say?” vs “I’m hearing you right, you are angry about it. Can you let me understand what makes you so angry?”
“You are asking into so much details that even if I try to explain it may still be difficult for you to understand the complex pathophysiology” vs “I can feel that you love your father so much that you ask into such details. Let me try my best to help you understand.”

12. Establishment of time-limited goals based on clinical judgement
“If we see no signs that your father has improved over the next 72 hours, then we believe you should consider withdrawing life support. We believe your father is suffering and has essentially no change to regain any reasonable quality of life, and to withdraw life support would allow him a more peaceful and dignified death.”

13. Pearls
No respectable physician should be pushed by relatives into giving treatment that is not medically indicated
Good medical care and use common sense
Treatment with everything that should be done – not everything that can be done