END OF LIFE DECISIONS ABOUTWITHHOLDING OR WITHDRAWING THERAPY    MEDICAL, ETHICAL AND RELIGIO-CULTURAL               CONSI...
Author: Dr. Liza C. Manalo, MSc.         Palliative Care Unit, Cancer Center, The Medical City, Pasig City &Supportive & P...
What happens towards the end of life?                   Physicians face dilemmas of              discontinuing life-sustai...
What does this mean?Should life-sustaining treatment be continued just the same?
The withholding and withdrawing of life-sustaining therapies could be  ethical and medically appropriate, as when the trea...
Physicians are not obligated to and should not offer or provide                useless or futile treatments, i.e.,    trea...
WHY?Due to fear of legal repercussions/misconceptions, limited physician- patient relationships, time constraints, institu...
Blackhall asked why physicians continued to consider CPR for patients             even though it was known to offer no ben...
Patients typically do not make these decisions proactively.It is the family members who often decide on the patient’s beha...
It is much easier and less uncomfortable for physicians to present CPR   as an option than to inform a patient that she wi...
Doctor-patient discussions about end-of-life treatment are often framed   as a choice between ―medical treatment vs. treat...
In a study by Eliott and Olver, a common assumption underpinning     patients’ and families’ discussions about a DNR decis...
Alternatively, the choice to opt for CPR might sentence their loved one                  to life in unacceptable circumsta...
Communication is key to all these types of discussion.Very often it is perceived that if CPR is performed, a patient will ...
DNR should be in the context of a discussion about the           patient’s understanding of his or her illness,           ...
There are many factors involved in decisions to limit life-sustaining             therapy:            MEDICAL             ...
From the medical perspective, the first requirement is that there is at   least acceptance and at best consensus among the...
Patients’ and families’ religious-cultural backgrounds profoundly influence their preferences and needs regarding discussi...
In certain cultures, such as the Philippines, removing the ventilator and            giving opioids could be perceived as ...
Withholding or withdrawing life-sustaining therapies that are             disproportionate to the expected outcome is     ...
Even so, some family members may be reluctant to withdraw treatments             even when they believe that the patient w...
Withholding and withdrawing therapy requireattending physicians to be excellent communicators            with patients and...
The Institute for Clinical Systems Improvement (ICSI) Palliative Care        Guideline recommends shared decision-making a...
Acceptable clinical practice on withdrawing or    withholding treatment is based on an understanding    of the medical, et...
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Considerations when deciding about withholding or withdrawing life-sustaining therapy

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Towards the end of life, physicians face dilemmas of discontinuing life-sustaining treatments or interventions. In some circumstances, these treatments are no longer of benefit, while in others the patient or family no longer want them. The physician plays an essential role in clarifying the goals of medical treatment, defining the care plan, initiating discussions about life-sustaining therapy, educating patients and families, helping them deliberate, making recommendations, and implementing the treatment plan. Communication is key. It should be clarified that when inevitable death is imminent, it is legitimate to refuse or limit forms of treatment that would only secure a precarious and burdensome prolongation of life, for as long as basic humane, compassionate care is not interrupted. Agreement to DNR status does not preclude supportive measures that keep patients free from pain and suffering as possible. Acceptable clinical practice on withdrawing or withholding treatment is based on an understanding of the medical, ethical, cultural, and religious issues. There is a need to individualize care option discussions to illness status, and patient and family preferences, beliefs, values, and cultures. The process of shared decision making between the patient, the family, and the clinicians should continue as goals evolve and change over time.

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Considerations when deciding about withholding or withdrawing life-sustaining therapy

  1. 1. END OF LIFE DECISIONS ABOUTWITHHOLDING OR WITHDRAWING THERAPY MEDICAL, ETHICAL AND RELIGIO-CULTURAL CONSIDERATIONS
  2. 2. Author: Dr. Liza C. Manalo, MSc. Palliative Care Unit, Cancer Center, The Medical City, Pasig City &Supportive & Palliative Care Service, Department of Community & Family Medicine, FEU-NRMF Medical Center, Quezon City, PHILIPPINES
  3. 3. What happens towards the end of life? Physicians face dilemmas of discontinuing life-sustaining treatments …In some circumstances, these treatments are no longer of benefit,while in others the patient or family no longer want them…
  4. 4. What does this mean?Should life-sustaining treatment be continued just the same?
  5. 5. The withholding and withdrawing of life-sustaining therapies could be ethical and medically appropriate, as when the treatment no longer fulfills any of the goals of medicine: to cure, if possible, or to palliate symptoms, prevent disease or disease complications, or improve functional status..
  6. 6. Physicians are not obligated to and should not offer or provide useless or futile treatments, i.e., treatments that no longer offers benefit to the patient. Even in the name of patient autonomy.And yet, physicians still seek and obtain patient or proxy consent when CPR is not indicated before writing a Do Not Resuscitate (DNR) order.
  7. 7. WHY?Due to fear of legal repercussions/misconceptions, limited physician- patient relationships, time constraints, institutional culture, guilt, grief, and concerns about the family’s reaction. Other obstacles are insufficient legal and palliative knowledge, and treatment requests by patients or families.
  8. 8. Blackhall asked why physicians continued to consider CPR for patients even though it was known to offer no benefit…Physicians, due in part to their own discomfort with death and dying, tended to avoid end-of–life discussions. Hence, CPR and DNR conversations often didn’t take place in the non-acute setting.
  9. 9. Patients typically do not make these decisions proactively.It is the family members who often decide on the patient’s behalf. Family members are then faced with the pressure of considering —on the spot—what their loved one ―would have wanted.‖ Most patients lacked the medical knowledge needed to fully understand the role of CPR. Blackhall challenged the presumption that patients always have a right to CPR any more than they have a right to receive a medically nonsensical treatment.
  10. 10. It is much easier and less uncomfortable for physicians to present CPR as an option than to inform a patient that she will die soon regardless of the intervention. Physicians were, on average, rather poor at having these discussions.
  11. 11. Doctor-patient discussions about end-of-life treatment are often framed as a choice between ―medical treatment vs. treatment withdrawal.‖ Treatment withdrawal becomes a negative choice that often implies giving up, abandonment, or not giving the doctor a chance to do his or her job, and worse, not caring. Thus, this option can appear to be no option at all.
  12. 12. In a study by Eliott and Olver, a common assumption underpinning patients’ and families’ discussions about a DNR decision is that it requires a choice between life and death.Choosing to forgo CPR was construed as choosing to let the patient die. Either the patient was not worth saving, or the family did not care enough to save them.
  13. 13. Alternatively, the choice to opt for CPR might sentence their loved one to life in unacceptable circumstances.
  14. 14. Communication is key to all these types of discussion.Very often it is perceived that if CPR is performed, a patient will be resurrected from the dead and will be well.. This view can be a barrier to decision making.
  15. 15. DNR should be in the context of a discussion about the patient’s understanding of his or her illness, prognosis, and goals of care.The patient should be made aware of the benefits and burdens of CPR. DNR does not mean “Do Not Treat.”Agreement to DNR does not preclude other supportive measures. Although CPR will not be given, maximal medical therapy that meets patient’s goals, and supportive measures that maximizes the patient’s comfort will continue.
  16. 16. There are many factors involved in decisions to limit life-sustaining therapy: MEDICAL ETHICAL RELIGIO-CULTURAL
  17. 17. From the medical perspective, the first requirement is that there is at least acceptance and at best consensus among the members of the health care team to limit therapy when hope for recovery is outweighed by burden of the treatmentTreatments should not be withheld because of the mistaken fear that if these are begun, they cannot later be withdrawn. Instead, a time limited trial of therapy could be used to clarify the patient’s prognosis. At the end of the trial, a conference should be held to review and revise the treatment plan.
  18. 18. Patients’ and families’ religious-cultural backgrounds profoundly influence their preferences and needs regarding discussing bad news, decision-making, and the dying experience.Studies have shown that non-white patients are less likely than white patients to agree to DNR orders or to withhold or withdraw care, and are less likely to have advance care directives.
  19. 19. In certain cultures, such as the Philippines, removing the ventilator and giving opioids could be perceived as mercy-killing. In accordance with the Vatican Declaration on Euthanasia, when inevitable death is imminent, it is permitted, with the patients consent, to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, andto interrupt means provided by the most advanced medical techniques where the results fall short of expectations.
  20. 20. Withholding or withdrawing life-sustaining therapies that are disproportionate to the expected outcome is NOT EUTHANASIA.It is in fact ethical and medically appropriate, for as long as the normal care due to the sick person is not interrupted.
  21. 21. Even so, some family members may be reluctant to withdraw treatments even when they believe that the patient would not have wanted them continued. The physician should try to resolve these situations by addressing the families’ feelings of guilt, fear, and concern that their ill relative may suffer as life support is withdrawn. The physician should ensure that all appropriate measures to relieve distress are used, as well as explain the physician’s ethical obligation to follow the patient’s wishes.
  22. 22. Withholding and withdrawing therapy requireattending physicians to be excellent communicators with patients and families . Jox et al proposed an algorithm that focuses primarily on goals of treatment, and secondarily on treatment measures. Two ethical grounds of treatment decisions: Patient autonomy & Patient wellbeing.
  23. 23. The Institute for Clinical Systems Improvement (ICSI) Palliative Care Guideline recommends shared decision-making and reframing the discussion from "medical futility― to a clarification of goals of care. This does not preclude the clinician making a strong treatment recommendation based on clinical knowledge and experience.
  24. 24. Acceptable clinical practice on withdrawing or withholding treatment is based on an understanding of the medical, ethical, cultural, and religious issues.There is a need to individualize care option discussions to illness status, and patient and family preferences, beliefs, values, and cultures.Shared decision-making on treatment preferences should be periodically revisited as the goals evolve and change over time. Full text available at: Palliative Care: Research and Treatment Libertas Academicahttp://www.la-press.com/end-of-life-decisions-about-withholding-or-withdrawing-therapy-medical-article-a3582

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