icu

Removal of Life-Sustaining Treatments

　　There is no ethical difference between withdrawing an ineffective treatment and not starting it in the first place. However, many clinicians do not find it easy to do this. Lack of experience or fear that sudden removal of a treatment will lead to immediate death may prompt a lack of action. It is my experience that if counseled carefully in advance, many families are comfortable with the removal of treatments that prolong death rather than life. In the ICU, there is usually a tracheal tube in place, and it matters little whether this is left in place during the dying process or not. It is prudent to counsel families that without the tube, a certain degree of "gasping" may be inevitable (it is the very last reflex to leave), but it certainly can be removed if that is their preference. Some families have very clear ideas of what is appropriate for them (often sadly because of a previous bad experience) and others ask for help and guidance. Some general principles that this author has found helpful are listed below:
　

　Remove those treatments that will have the least immediate effect first. For example, orders to discontinue antibiotics, prophylactic heparin, and H2 blockers will lay foundations without obvious changes in the acute physiological state.
　

　Concentrate on the positive aspects of the process-- eg, ending of suffering, relief of pain, no further uncomfortable investigations or biopsies, and so on.
　

　Verbalize that it is OK for the family to be scared, but that the decision is still the correct one.
　

　Realize that death is a very traumatic event for the survivors, and that it comes as a shock even for the best prepared.
　

　Avoid time frames. We never know when a patient will die.
　

　Encourage the family to focus on the patient, not the monitors.
　

　Do not burden the family with needless guilt. The decision to withdraw medical therapies remains a medical one; however you are seeking their support in making the decision.
　

　Use judgment when using religious connotations. Families benefit enormously from appropriate spiritual support, but this is by no means universal.
　

　Verbalize that ignorance of the formalities of death is OK and that there are usually plenty of people to help with these details.
　

　Gain consensus from all stakeholders -- eg, medical and nursing staff; pastoral and social workers; and family members. (Make sure all those with an interest know the plan.) Probably the most important aspect of high-quality end-of-life care is general agreement on why, how, and when the treatment withdrawal process will take place. This is no time for surprises.
　

　Emphasize the change in focus from cure to palliation. Stress that this in no way represents "giving up."
　

　Be aware that families deal with grief differently.
　

　One can be sorry without having done anything wrong.
　

　Remember that it is the patient with the disease; staff should be compassionate and involved, but not to the extent that it adversely affects the care they give their own family and the next patient.