Withdrawal and limitation of life support in paediatric intensive care.
OBJECTIVES: To compare the modes of death and factors leading to withdrawal or limitation of life support in a paediatric intensive care unit (PICU) in a developing country. METHODS: Retrospective analysis of all children (< 12 years) dying in the PICU from January 1995 to December 1995 and January 1997 to June 1998 (n = 148). RESULTS: The main mode of death was by limitation of treatment in 68 of 148 patients, failure of active treatment including cardiopulmonary resuscitation in 61, brain death in 12, and withdrawal of life support with removal of endotracheal tube in seven. There was no significant variation in the proportion of limitation of treatment, failure of active treatment, and brain death between the two periods; however, there was an increase in withdrawal of life support from 0% in 1995 to 8% in 1997-98. Justification for limitation was based predominantly on expectation of imminent death (71 of 75). Ethnic variability was noted among the 14 of 21 patients who refused withdrawal. Discussions for care restrictions were initiated almost exclusively by paediatricians (70 of 75). Diagnostic uncertainty (36% v 4.6%) and presentation as an acute illness were associated with the use of active treatment. CONCLUSIONS: Limitation of treatment is the most common mode of death in a developing country's PICU and active withdrawal is still not widely practised. Paediatricians in developing countries are becoming more proactive in managing death and dying but have to consider sociocultural and religious factors when making such decisions. (+info)
Bone marrow transplant patients with life-threatening organ failure: when should treatment stop?
PURPOSE: To discuss issues surrounding life support in bone marrow transplant (BMT) patients, issues that may determine how far we go to keep a deteriorating BMT patient alive--and when we stop trying. How can we define survival chance in BMT patients, and when should prolongation of life be deemed inappropriate? Who should make the decision to terminate support? And how should life support be terminated? DESIGN: Prognostic factors that predict for almost certain nonsurvival have been identified in BMT patients with life-threatening organ failure. The concept of futility raises the question of how low the chance of survival must be before termination of life support is justified--but the concept is flawed, and the value judgments involved in decision making must also be considered. Then, once a decision is made, the manner of withholding or withdrawing life support is also open to discussion. CONCLUSION: Despite controversies, there are areas in which improvements to current practice might be considered. More data are required to determine survival chances of BMT patients with life-threatening organ failure. Greater attention might be devoted, in pretransplant counseling, to issues of intensive life support, with the patient's own views being ascertained before transplantation. And, because technologic possibilities are now imposing fewer boundaries, the problem of finite resources may need to be readdressed, with treatment limits being set down before transplantation. (+info)
Life support in the intensive care unit: a qualitative investigation of technological purposes. Canadian Critical Care Trials Group.
BACKGROUND: The ability of many intensive care unit (ICU) technologies to prolong life has led to an outcomes-oriented approach to technology assessment, focusing on morbidity and mortality as clinically important end points. With advanced life support, however, the therapeutic goals sometimes shift from extending life to allowing life to end. The objective of this study was to understand the purposes for which advanced life support is withheld, provided, continued or withdrawn in the ICU. METHODS: In a 15-bed ICU in a university-affiliated hospital, the authors observed 25 rounds and 11 family meetings in which withdrawal or withholding of advanced life support was addressed. Semi-structured interviews were conducted with 7 intensivists, 5 consultants, 9 ICU nurses, the ICU nutritionist, the hospital ethicist and 3 pastoral services representatives, to discuss patients about whom life support decisions were made and to discuss life-support practices in general. Interview transcripts and field notes were analysed inductively to identify and corroborate emerging themes; data were coded following modified grounded theory techniques. Triangulation methods included corroboration among multiple sources of data, multidisciplinary team consensus, sharing of results with participants and theory triangulation. RESULTS: Although life-support technologies are traditionally deployed to treat morbidity and delay mortality in ICU patients, they are also used to orchestrate dying. Advanced life support can be withheld or withdrawn to help determine prognosis. The tempo of withdrawal influences the method and timing of death. Decisions to withhold, provide, continue or withdraw life support are socially negotiated to synchronize understanding and expectations among family members and clinicians. In discussions, one discrete life support technology is sometimes used as an archetype for the more general concept of technology. At other times, life-support technologies are discussed collectively to clarify the pursuit of appropriate goals of care. CONCLUSIONS: The orchestration of death involves process-oriented as well as outcome-oriented uses of technology. These uses should be considered in the assessment of life-support technologies and directives for their appropriate use in the ICU. (+info)
Withholding/withdrawing treatment from neonates: legislation and official guidelines across Europe.
Representatives from eight European countries compared the legal, ethical and professional settings within which decision making for neonates takes place. When it comes to limiting treatment there is general agreement across all countries that overly aggressive treatment is to be discouraged. Nevertheless, strong emphasis has been placed on the need for compassionate care even where cure is not possible. Where a child will die irrespective of medical intervention, there is widespread acceptance of the practice of limiting aggressive treatment or alleviating suffering even if death may be hastened as a result. Where the infant could be saved but the future outlook is bleak there is more debate, but only two countries have tested the courts with such cases. When it comes to the active intentional ending of life, the legal position is standard across Europe; it is prohibited. However, recognising those intractable situations where death may be lingering and unpleasant, Dutch paediatricians have reported that they do sometimes assist babies to die with parental consent. Two cases have been tried through the courts and recent official recommendations have set out standards by which such actions may be assessed. (+info)
Re-examining death: against a higher brain criterion.
While there is increasing pressure on scarce health care resources, advances in medical science have blurred the boundary between life and death. Individuals can survive for decades without consciousness and individuals whose whole brains are dead can be supported for extended periods. One suggested response is to redefine death, justifying a higher brain criterion for death. This argument fails because it conflates two distinct notions about the demise of human beings--the one, biological and the other, ontological. Death is a biological phenomenon. This view entails the rejection of a higher brain criterion of death. Moreover, I claim that the justification of the whole brain (or brain stem) criterion of death is also cast into doubt by these advances in medical science. I proceed to argue that there is no need to redefine death in order to identify which treatments ought to be provided for the permanently and irreversibly unconscious. There are already clear treatment guidelines. (+info)
Decisions at the end of life.
This paper presents a system for making decisions at the end of life. It emphasizes the role of patient autonomy and the importance of patient and family participation with the physician in decision-making. Definitions are presented for the terms: terminal illness, withholding and withdrawing life sustaining treatment, physician assisted suicide and euthanasia. Three cases are briefly described to illustrate the application of the decision-making system. A detailed discussion is then presented of the divergent views expressed by different authors about the moral differences or similarities between foregoing life sustaining treatment and physician assistance in dying. It is concluded that the view that these two actions are fundamentally different, as supported by the United States Supreme Court, in 1997, is the correct one. Physician assisted suicide (PAS) remains a controversial issue. Physicians and societies in individual countries must work out their own approaches to PAS. However, foregoing invasive or intensive life support in terminally ill patients consistent with their wishes is considered appropriate. (+info)
Causal authorship and the equality principle: a defence of the acts/omissions distinction in euthanasia.
This paper defends the acts/omissions distinction which underpins the present law on euthanasia, from various criticisms (including from within the judiciary itself), and aims to show that it is supported by fundamental principles. After rejecting arguments that deny the coherence and/or legal relevance of the distinction, the discussion proceeds to focus on the causal relationship between the doctor and the patient's death in each case. Although previous analyses, challenging the causal efficacy of omissions generally, are shown to be deficient, it is argued that in certain cases of causing death by omission the causal authorship of the doctor lapses. The final part of the paper examines why this should be morally significant and proposes an answer in terms of the principle of equality. Assuming all other factors are equal, the infringement of this principle provides an additional reason against actively killing a patient, which is not present in cases of passively letting die. (+info)
Avoiding anomalous newborns: preemptive abortion, treatment thresholds and the case of baby Messenger.
In its American context the case of baby Messenger, a preterm infant disconnected from life-support by his father and allowed to die has generated debate about neonatal treatment protocols. Limited by the legal and ethical norms of the United States, this case did not consider treatment protocols that might be available in other countries such as Denmark and Israel: threshold protocols whereby certain classes of newborns are not treated, and preemptive abortion allowing one to choose late-term abortion rather than risk delivery. Each offers a viable and ethically sound avenue for dealing with the economic and social expense of anomalous newborns by aborting or not treating those most likely to burden the health care system. Objections that these protocols are antithetical to American bioethical principles are considered but rejected as each policy answers to economic justice, utility and respect for autonomy. (+info)