Untitled

Abstract

The majority of deaths on the intensive care unit now occur following a decision to limit life-sustaining therapy, and end-of-life decision making is an accepted and important part of modern intensive care medical practice. Such decisions can essentially take one of two forms: withdrawing -the removal of a therapy that has been started in an attempt to sustain life but is not, or is no longer, effective -and withholding -the decision not to make further therapeutic interventions. Despite wide agreement by Western ethicists that there is no ethical difference between these two approaches, these issues continue to generate considerable debate. In this article, I will provide arguments why, although the two actions are indeed ethically equivalent, withdrawing lifesustaining therapy may in fact be preferable to withholding. IntroductionEnd-of-life decision making for the intensive care unit (ICU) patient has been a hot topic in recent years, with the acknowledgement that such practice is common worldwide [1] and with a new openness among doctors and laypersons regarding the once rather taboo subject of death. Indeed, because the majority of ICU deaths now occur following a decision to limit life-sustaining therapy [2][3][4][5][6], it is important that these often difficult ethical areas be discussed openly.Essentially, a decision to limit life-sustaining therapy can take one of two forms: withholding or withdrawing. Withdrawal of therapy is relatively easily defined as the removal of a therapy that was started in an attempt to sustain life but has become futile and is just prolonging the dying process. Withdrawal usually concerns therapies such as mechanical ventilation and administration of vasoactive agents. Withholding therapy, on the other hand, concerns the concept of no therapeutic escalation. Perhaps the most frequent example of this is the do not resuscitate (DNR) order (or DNAR -do not attempt to resuscitate). Withholding resuscitation efforts will almost inevitably result in death from a cardiac arrest should one occur. It is important to make this decision in advance because once the cardiac arrest occurs there is no time to think -each second counts. In many advanced cases the DNR order is not sufficient (e.g. the patient with terminal cancer or just very advanced age), and hence do not escalate (DNE) orders (e.g. no mechanical ventilation in respiratory failure or no extracorporeal support in terminal renal failure) may be used. However, it is important to define clearly what is included in a DNE order because less aggressive interventions such as antibiotic use or nasogastric tube feeding may not be seen as significant escalation and could still be given.The vast majority of doctors accept the principal and application of withholding; indeed, if life-sustaining therapies were not withheld from some patients, ICUs would be full of terminally ill patients with no hope of recovery. The only real objectors to the withholding of therapy are a few individuals with very strongly held religious beliefs...

Experiences of Slovene ICU Physicians with End-of-Life Decision Making: A Nation-Wide Survey

“…We could thus discriminate between the “soft” (e.g., withdrawal of inotropes or antibiotics) and the “hard” (e.g., extubation or withdrawal of mechanical ventilation) measures of withdrawal of LST, in line with the fact that the first were reported to be much more commonly used than the later. The “soft” measures might thus be preferable for the ICU physicians from a practical point of view, despite no difference or even some opposite claims with regard to the ethical point of view found in the literature [ 34 ]. Nevertheless, also most previous surveys indicated that withdrawal of therapy is more difficult for ICU physicians than withholding therapy [ 11 , 12 , 18 ].…”

SAPS 3—From evaluation of the patient to evaluation of the intensive care unit. Part 1: Objectives, methods and cohort description

“…On the following days of the ICU stay, further information was collected: severity of illness, as measured by the SAPS II [5]; number and severity of organ dysfunction, as measured by the Sequential Organ Failure Assessment (SOFA) [28]; length of ICU and hospital stay; and outcome data, including vital status at ICU and hospital discharge. All patients were subjected to mandatory follow-up until hospital discharge, but not longer than 90 days after ICU admission.…”

Advances in Extracorporeal Detoxification by MARS Dialysis in Patients with Liver Failure

“…A multi-center randomized trial, including one parallel arm treated with conventional therapy, is the most reliable way to enforce today's results, but the difficulty to draw a definitive conclusion on a new therapeutic intervention in the clinical setting of intensive care, even if resulting from a randomized controlled trial, should be take under consideration [54].…”