WithholdingWithdrawing Life Support

1
Withholding/Withdrawing Life Support

• Gilbert Handal, M.D.
• February 2003

2
Royal College of Pediatricians

• Situations where it would condone allowing sick
  children to die
• Child is in a persistent vegetative state.
• Child with severe disease and treatment could
  delay death but not stop suffering.
• Treatment would leave the child with an
  unreasonable disability.
• Further treatment is more than the family or the
  child can bear.
• Information Medethics.alliance.org

3

• Futile, inappropriate experimental or
  unreasonable medical care should not be provided
  even if requested
• AM. Rev of Respiratory Dis. 1991 144 (3pt1)
  726-31
• JAMA 1993, 2702213-7

4

• Etmographic interviews documented a deep distrust
  towards the health care system and a fear that
  health care was based on ones ability to pay.
• Ethnicity is strongly related towards W W life
  support.
• Relationships are complex and sometimes
  contradictory
• Soc. Sic med 1999481779-89
• In with drawing life support the use of
  analgesia/sedation is considered essential
  hastening of death as a consequence of its use is
  considered an unintended side effect

5
Determinants in HCW of the decision to
withdrawing life support in IW care

• Likelihood of surviving actual episode
• Likelihood of long term survival
• Pre-morbid cognitive status
• Age of patient
• Extreme variability determined in part by values
  of HCW.

6

• On a prospective study of patients dying at a PIW
• 25 died
• 1. Brain Dead
• 2. Failure of CPR
• 3. DNR
• 4. WDFS

7

• Prism was similar on all four groups
• (Ped Risk of Mortality)

8
Differences in decision making for WD WHLS
between US and French ICU

• Participation of proxies in the decision
• Evaluation of pts perception of quality of life
• Evaluation of pts wishes
• Eval. of pts religious values
• Eval. Of cost of treatment
• Medical team advise
• Reversibility of Acute Disease
• Underlying disease severity
• Patients quality of life

• US (French)
• 60 17
• 60-70 11.
• ? 7.6
• ? 7.6
• ? 7.6
• ? 95.3
• ? 90.5
• ? 83.9
• ? 80.1

9
Change of practices identified in IW towards

• Decreased use of CPR (Now 23)
• Variations in practice determined by
  practitioners values.
• There are no recognized standards of practice

10
Order of withdrawals AJM 1999107153-6

• Blood products
• Hemoalysis
• Vasopressors
• Mechanical ventilation
• TPN
• Antibiotics
• IV fluids
• NG tube feeding

11
Withholding Life Support

• Parental powers should be curtailed if
• - the treatment refused would provide a
• clear benefit to the child
• - Statistical chances of recovery are
• good
• - Where the severity and burdens of
• the condition are not sufficient time WH
• WD life prolonging treatment.

12

• Parents cannot necessarily insist on enforcing
  decisions based solely on their own preferences
  where there is conflict with good medical
  evidence.

13
Refusal of Medical Treatment

• Early involvement of the attending
• Inform the parents of
• 1. Consequences
• 2. Alternative therapies available
• 3. Actions that may be taken in the
• worsening of the situation.
• 4. Transfer options
• 5. Other pertinent information
• The refusal of care, may make other care
  irrelevant
• CPS should be involved to protect the interest of
  the child as needed.
• The ethics committee can be consulted.

14
Withholding and Withdrawing Life Support

• Doubt resolved in favor of treatment until the
  disagreements are resolved, treatment should
  continue.
• Non treatment if the patient is dead.
• The primary responsible for WH WD life is the
  attending physician.
• Documentation
• - appropriate forms
• - appropriate orders
• Continuation of other care.
• No physician should be forced to WH or WD LS,
  when doing so, would be contrary to his
  conscience or his professional judgment.
• No physician has a duty to provide useless or
  futile treatment.