From the Guidelines
When discontinuing care, healthcare providers have a legal and ethical obligation to prioritize patient welfare and safety, ensuring continuity of care and preventing harm from treatment interruption, as emphasized in the American College of Physicians position paper 1. To fulfill this obligation, providers must:
- Be present and listen to the patient, exploring the reasons for the request to discontinue care and seeking alternative solutions where possible 1
- Affirm that they will care for and not abandon the patient, accompanying and advising the patient through the journey of end-of-life care 1
- Discuss patient goals of care and the nature of curative and comfort care, explaining a both/and approach to disease-oriented and palliative care 1
- Facilitate advance care planning and an understanding of surrogate decision making, as desired by the patient 1
- Ensure that the patient is fully informed of the right to refuse treatments and what that entails 1
- Discontinue or do not start medications and interventions that interfere with the patient's values, goals, and preferences 1
- Assess and treat the patient's pain and other distressing physical and psychological symptoms 1
- Assess and optimize patient function through a whole-patient focus 1
- Coordinate, as desired by the patient, the efforts of other members of the healthcare team, and use community-based resources to address financial, emotional, and spiritual burdens on the patient and family 1
- Prepare the patient and family for what they can expect as illness progresses, addressing uncertainty together and ensuring that the patient and family have informed expectations 1
- Regularly assess the patient's status and decision-making capacity 1
- Arrange hospice care at home if that is the patient's preference, being cognizant that palliative and hospice care can be provided concurrently with curative care 1 Additionally, the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1 emphasize the importance of limiting care or withdrawing life-sustaining therapies in a manner that prioritizes patient autonomy, comfort, and dignity, and that interventions that minimize suffering and pain should always be provided. Ultimately, the key principle is to prioritize patient welfare and safety, ensuring that care is not abandoned and that the patient's needs are met throughout the discontinuation process, as supported by the most recent and highest quality evidence 1.
From the Research
Legal Obligations
- The law respects a competent patient's right to direct their healthcare, but does not uphold their right to demand futile care 2.
- Surrogate decision makers can be used when the patient is incompetent, provided they are acting in the patient's best interest 2.
- Euthanasia is illegal, and the distinction between discontinuation of therapy and euthanasia is legally clear 2.
Ethical Obligations
- Understanding the ethical principles of autonomy, beneficence, non-maleficence, and double effect are crucial when withdrawing life support therapy 2.
- The clinician's responsibility to the patient does not end with a decision to limit medical treatment, but continues through the dying process 3.
- Every effort should be made to ensure that withdrawing life support occurs with the same quality and attention to detail as is routinely provided when life support is initiated 3.
Practical Considerations
- Discontinuing life-sustaining interventions requires an artful skill, and critical care nurses require advanced skills to provide comfort care and a "good death" that encompasses the family and patient 4.
- Seven steps can be followed to assist in discontinuing life-sustaining treatment, including talking with the family, ensuring orders are written, preparing drugs, and proceeding with the discontinuation 4.
- Approaching the withdrawal of life support as a medical procedure provides clinicians with a recognizable framework for their actions, and key steps include identifying and communicating explicit shared goals and preparing protocols and materials to assure consistent care 3.
- Every ICU should develop its own guidelines and a checklist to help caregivers during this difficult time, and caregivers must anticipate the mechanism of death and direct interventions at the symptoms that are likely to cause discomfort 2.