Withdrawing or withholding life prolonging treatment

Luttrell, Steven

doi:10.1136/bmj.318.7200.1709

Cited by 18 publications

(5 citation statements)

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“…In each case, whether withholding or withdrawing, we decide which treatment is to be applied in the immediate future, and the immediate result will be the same regardless of the situation prior to the decision. Western ethicists have largely defended this view of equivalence [5,9-12], and various groups have published guidelines supporting this standpoint. For example, the Belgian Society of Intensive Care Medicine [13] states clearly that there is no ethical or moral difference between withholding and withdrawing life-sustaining therapy, and the British Medical Association's guidelines [14] state that, 'Although emotionally it may be easier to withhold treatment than to withdraw that which has been started, there are no legal, or necessary morally relevant, differences between the two actions'.…”

Section: Withdrawal Is Ethically Equivalent To Withholding At the Endmentioning

confidence: 99%

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Vincent

2005

Crit Care

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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...

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Section: Withdrawal Is Ethically Equivalent To Withholding At the Endmentioning

confidence: 99%

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Vincent

2005

Crit Care

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“…Just as the decision in Airedale NHS Trust v Bland 114 left 'some British doctors in an odd and uncomfortable position' even though the decision ended a decade in which doctors had made difficult decisions about withdrawal of life-prolonging treatment 'in a vacuum, without legal or professional guidance', 115 neither the common law in England nor the common law and criminal codes in Australia are equipped to deal with the legal dilemmas posed by sacrificial separation surgery. The English Court of Appeal's decision in Re A (Children) and the Queensland Supreme Court decision in Nolan do not provide a principled legal basis for exculpating doctors who perform sacrificial separation surgery.…”

Section: Vi: Conclusionmentioning

confidence: 99%

Criminal Law Implications for Doctors Who Perform Sacrificial Separation Surgery on Conjoined Twins in England and Australia

Davis

2014

VULJ

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There are two reported cases in which courts have been asked to declare lawful surgery to separate conjoined twins where it is known that one twin will die during the procedure. Although judges granted the declaration sought, the two written decisions one from the common law jurisdiction of England and Wales, the other from a code jurisdiction in Queensland, Australia are problematic. This paper argues that neither of these cases provides a principled or certain basis for exculpating doctors in a future conjoined twin case, particularly if this case does not involve infant conjoined twins, one of whom is dying or is severely disabled. 5 This paper uses the term 'defence' in its general sense to refer to defences, justifications and excuses. 6 In some cases, the twin selected to be sacrificed is not complete. The law of homicide will be relevant only if the incomplete twin is a person capable of being killed. See Colleen Davis, 'Conjoined Twins as Persons that can be Victims of Homicide' (2011) 19(3) Medical Law Review 430.

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“…The recently published BMA guidance document takes this matter further 7 – 8. It too hopes that it will eventually be decided that cases of withdrawal of treatment in cases of persistent vegetative state should no longer require court review provided that the withdrawal is undisputed and accords with agreed guidance.…”

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confidence: 99%

Should cases of permanent vegetative state still go to court?

Jennett

1999

BMJ

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Withdrawing or withholding life prolonging treatment

Cited by 18 publications

References 1 publication

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Criminal Law Implications for Doctors Who Perform Sacrificial Separation Surgery on Conjoined Twins in England and Australia

Should cases of permanent vegetative state still go to court?

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