Withholding and Withdrawing Life-Sustaining Treatment: Euthanasia or Acceptable Medical Practice?

Maria Fidelis C. Manalo, MD, MSc.

Department of Community and Family Medicine

Physicians are not ethically obligated to deliver care that, in their best professional judgment, will not have a reasonable chance of benefiting their patients. When further intervention to prolong the life of a patient becomes futile, physicians have an obligation to shift the intent of care toward comfort and closure. Withholding or withdrawing life-sustaining therapies is ethical and medically appropriate in these circumstances. Before reviewing specific treatment preferences, it is useful to ask patients about their understanding of the illness and to discuss their values and general goals of care. Attending physicians should feel free to make a referral to the specialist palliative care service if they need assistance in providing specific advice to patients and families struggling with these end-of-life decisions. Terminally-ill patients with decisionmaking capacity can opt to forego any medical intervention, including artificial nutrition/hydration and cardiopulmonary resuscitation.

Case presentation:
Mrs. S is a 42-year-old female with ovarian cancer with pulmonary metastasis. She was admitted with dehydration, weakness, and pneumonia in the immunocompromised. Her cancer treatments have failed, as she now has a recurrence. The oncologist is contemplating some new palliative chemotherapy once the pneumonia resolves. The attending physician is concerned about her cachexia and recommends total parenteral nutrition (TPN). Should the patient be started on TPN? During the patients course in the ward, the patients pneumonia progressed rapidly. The doctors anticipated that she might go into respiratory failure. Awake and alert, the patient verbally communicated to the attending physicians that she wants to die with dignity and does not want to be hooked to a respirator. However, before the patient was able to sign the advance directives, she went into respiratory distress to the point of cardiorespiratory arrest. The husband decided on and authorized a full code for her. She was subsequently resuscitated after 15 minutes, was attached to mechanical ventilation and was transferred to the ICU. What do you think is the prognosis of the patient? What else do you want to know before making the decision to withhold or withdraw ventilator support? If she was competent, will you honor her request? What if the family requests continuation of ventilator support

and other life-sustaining treatment that the health care team considers futile?

Quality of Life
Quality of life are judgments about the kind of life a patient experiences before or after the use of medical interventions. While there are disagreements about the meaning of the termeven whether or not such judgments can be made and can be made fairly and objectively or are necessarily subjective and arbitrary the concept does exist within the Catholic moral tradition. The term should not be understood, however, as evaluations of the individuals merit or moral worth. Though all human life is inherently valuable as considered in the principles of human dignity and sanctity of life, physical life is not an absolute value, but only the condition for the pursuit of higher values. In other words, purely physical life is a penultimate value, but not the ultimate value of human life (John Paul II, Evangelium vitae 2). "Quality of life judgments, then, are assessments about a patients current or future medical condition in relation to his or her abilities to pursue these other important values that transcend physical life. Any decision to use medical technology must consider whether the intervention will enhance or diminish the patients ability to pursue lifes values beyond merely physical existence" (McBrien, 1995). Quality of life considerations may be included in ones evaluation of a medical treatment as a proportionate or

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disproportionate means, but may not be the sole determining factor (Ascension Health, 2012).

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Table 1. Things to think about when considering a referral to palliative care* What are your teams plans for ongoing care? What treatment options are available? What are the patients wishes for care or place of care? If there are symptoms, what do you think is the underlying cause and what steps have already been taken to address them? If the referral is for terminal care, has your team reached a consensus that this is the aim of care? Is this reflected in the care that is being provided? Have you thought through and identified the specialist palliative care needs of your patient, e.g. difficulties of pain and symptom management, psychological and social needs and dying? Have you made sure that the patient and family are aware of and in agreement with the palliative care referral? This will usually imply a level of understanding of their illness and prognosis. * Watson et al, Oxford Handbook of Palliative Care, 2009 Many patients turn to family members, friends, or caregivers for advice. But it is the patient's decision how much or how little treatment to have (Snyder, 2012).

Palliative Care
Palliative care is both a philosophy of care and an organized highly structured system for delivering care to persons with life-threatening or debilitating illness. Palliative care is neither about shortening life nor prolonging the dying period. It is a patient and familycentered care that focuses upon effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient/family needs, values, beliefs, and culture(s). The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease and the need for other therapies. Palliative care can be delivered concurrently with life-prolonging care or as the main focus of care. (NCCN Practice Guidelines in Oncology-v.2.2011) Although palliative care goes beyond end-of-life care, palliative care near the end of life entails addressing physical, psychosocial, and spiritual needs, and understanding that patients may at times require palliative treatment in an acute care context such as in the emergency department (ED) or in the intensive care unit (ICU) (Synder, 2012). Appropriate and timely palliative care referral is based on an understanding of the goals of care, taking into consideration the patients and familys wishes, and how the palliative care specialist can assist in achieving these goals. (Table 1).

Advance Care Planning

Advance care planning allows a person with decision making capacity to develop and indicate preferences for care and choose a surrogate to act on his or her behalf in the event that he or she cannot make health care decisions. It allows the patients values and circumstances to shape the plan with specific arrangements to ensure implementation of the plan. Physicians should routinely raise advance planning with adult patients with decision-making capacity and encourage them to review their values and preferences for future care with their surrogates and family members. This is often best done in the outpatient setting before an acute crisis. These conversations with the patient let the physician know the patients views about care preferences, enable documentation of patient wishes in the medical record, and allow the physician to reassure the patient that he or she is willing to discuss these sensitive issues and will respect patient choices. Written advance directives include living wills and the durable power of attorney for health care for appointing a surrogate to make decisions if the patient becomes unable to do so (Snyder, 2012).

Making Decisions Near the End of Life

Patients are entitled to complete information about their illness and how it may affect their lives, and they have the right to share or withhold that information from others. Patients should also be informed about any procedures and treatments that are planned, the benefits and risks, and any alternatives that may be available. Patients have the right to make decisions about their own treatment, the right to accept or refuse medical care. These decisions may change over time. In the face of worsening disease, some patients may want to try every available drug or treatment in the hope that something will be effective. Other patients may choose to forgo aggressive medical treatment.

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flexible enough. Living Wills tend to put the emphasis on the side of death. (Scholl Institute, 2005)

Advance directives should be readily accessible to health care professionals regardless of the site of care. When there is no advance directive and the patients values and preferences are unknown or unclear, decisions should be based on the patients best interests whenever possible, as interpreted by a guardian or a person with loving knowledge of the patient, if available. When making the decision to forgo treatment, many people give the most weight to reversibility of disease or dependence on life support, loss of capacity for social interaction, or nearness to death. Family members and clinicians should avoid projecting their own values or views about quality of life onto the incapacitated patient. Quality of life should be assessed according to the patients perspective (Karlawish, 1999; American Coll Physicians, 2001). The surrogate decision maker is obligated to act in accordance with patients previously expressed preferences or best interests. Some patients want their surrogates to strictly adhere to their expressed wishes. Others want their surrogates to have flexibility in decision making. Patients should specify what authority and discretion in decision making they are giving their surrogates (Snyder, 2012). Ideally, the process of discussing and writing advance directives should be ongoing, rather than a single event. Advance directives can be modified as a patient's situation changes. Even after advance directives have been signed, patients can change their minds at any time. As long as a patient remains competent to participate in medical decisions, advance directives are revocable. Informed decisions by competent patients always supersede any written directive. Advance directives are important because complex choices about end-of-life care are difficult even when people are well. If a person is seriously ill, these decisions can seem overwhelming. But patients should keep in mind that avoiding these decisions when they are well will only place a heavier burden on them and their loved ones later on. Communicating wishes about end-of-life care will ensure that people with life-limiting illness face the end of their lives with dignity and with the same values by which they have lived.

Resisting the new "Death Ethics"

The living will was originally invented in 1967 by two groups, the Euthanasia Society of America and Euthanasia Education Council, and was touted as a first step in gaining public acceptance of euthanasia. These groups had been struggling for years to get "mercykilling" bills (which would allow doctors to give disabled or dying patients lethal overdoses) passed in various state legislatures. Even Catholic hospitals and nursing homes now offer some kind of living will and most people falsely assume that such directives are automatically compatible with Church teaching. While it has always been true that futile or excessively burdensome treatment or care can morally be refused, the Catholic Church has long condemned causing or hastening death, whether by omission or commission (Valko, 1999). However, no living will is risk-free and even refusing to sign a living will is no guarantee that the "right to die" will not be exercised for the patient despite his/her wishes. The best defense now is to have a loving relative or friend who is informed about ethical options and who can legally speak for the patient if he/she cannot because of illness or injury. It is also crucial that the patient chooses a doctor without a "right to die" bias, preferably one with a good understanding of Catholic ethical principles and Natural Moral Law.

Durable Power of Attorney for Health Care

Durable power of attorney for health care is a legal form that states who the patient wants to make decisions about medical care. The person is authorized to speak for the patient only if the patient is unable to make his/her own medical decisions. It may also be called "health care proxy or agent," health care surrogate, or "medical power of attorney." While a Living Will binds a patient to the piece of paper he or she has signed, a Durable Power of Attorney allows an agent, designated by the patient, to make health care decisions for him or her. An agent who clearly understands a patient's wishes and agrees with his or her values can apply those wishes and values to specific situations which are so often unforeseen. For instance: many people do not wish to be on a respirator at the end of their lives, and so may indicate this in a Living Will. However, if they are in an accident long before the end of their life, and need to be on a respirator only temporarily, the Living Will they have signed,

Living Will
A living will is a set of instructions documenting a person's wishes about medical care intended to sustain life. Some of the problems with most living wills include: they may be either much too specific or too vague, do not adapt to the patient's condition and are not

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legally binds them to not receive this care. An agent designated by a Durable Power of Attorney could choose to allow the temporary treatment of a respirator, knowing that the patient would wish it in this case (Scholl Institute, 2005).

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Cardiopulmonary Resuscitation (CPR) and "DoNot-Resuscitate" (DNR) Directives

Cardiopulmonary resuscitation (CPR) can be administered both in the hospital for patients suffering cardiac arrest or outside a hospital by rescue crews called to save the lives of persons suffering cardiac arrest, and rescue teams routinely give CPR immediately. CPR very often saves lives, and persons whose lives have been saved by it and their families are then grateful to have their lives extended. But one can ask whether CPR, despite its good effect of saving a cardiac victim's life, is always the morally right thing to do and in the true best interests of the person. A DNR is an advance directive, legally recognized, physician order to forgo basic cardiac life support in the outpatient setting and advanced cardiac life support in the inpatient setting. (May, 2010). Intervention in the case of a cardiopulmonary arrest is inappropriate for some patients, particularly those for whom death is expected, imminent, and unavoidable. Because the onset of cardiopulmonary arrest does not permit deliberative decision making, decisions about resuscitation must be made in advance. Physicians should especially encourage patients who face serious illness or who are of advanced age (or their surrogates as appropriate) to discuss resuscitation. A DNR order applies only to cardiopulmonary resuscitation. Discussions about this issue may reflect a revision of the larger goals and means of the care plan, and the extent to which a change is desired in treatment goals or specific interventions must be explicitly addressed for each patient. A DNR order must be written in the medical record along with notes and orders that describe all other changes in the treatment goals or plans, so that the entire health care team understands the care plan. A DNR order does not mean that the patient is necessarily ineligible for other life-prolonging measures, therapeutic and palliative. A patient who is a candidate for intubation but declines will develop respiratory failure and is expected to arrest. For this reason, physicians should not write a do-not-intubate (DNI) order in the absence of a DNR order. Moreover, it is important to address the patients or surrogates wishes regarding intubation and intensive care unit transfer in tandem with discussions about resuscitation.

A DNR order should not be suspended simply because of a change in the venue of care. When a patient with a preexisting DNR order is to undergo, for example, an operative procedure requiring general anesthesia, fiberoptic bronchoscopy, or gastroesophageal endoscopy, the physician should discuss the rationale for continuing or temporarily suspending the DNR order. A change in DNR status requires the consent of the patient or appropriate surrogate decision maker (Snyder, 2012).

"Extraordinary" or "Disproportionate" Means of Life Support

The Vatican Declaration on Euthanasia (1980) thus says that a "correct judgment" about treatments to be used can be made "by studying the type of treatment, its degree of complexity or risk, its cost and the possibility of using it, and comparing these elements with the results that can be expected, taking into account the state of the sick person and his or her physical and moral resources...one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome." Determining whether a treatment is ordinary or extraordinary depends upon the balance between two sets of factors. On one hand, we have to consider the physical, psychological, economic and other harm which a given modality of treatment is expected to cause, first of all, to a patient, but also to his or her relatives and friends as well as to society. On the other hand, we have to take into account the degree of probability, if any, first of all, that the patient will be cured or will be able, for a significant period of time, to live on under humanizing conditions. If the good outweighs the harm, then it can be reasonably affirmed that the means is morally ordinary (proportionate). If the harm outweighs the good, then disproportion probably exists and means is probably morally extraordinary. The Natural Moral Law and the Fifth Commandment of the Decalogue require that all ordinary means be used to preserve life. Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted. Food and water are natural means of sustaining life, not medical acts, even if delivered artificially. Nutrition and hydration are ordinary and proportionate means of care. Food and water are morally obligatory unless or until they cannot achieve their finality, which is providing nutrition and hydrating and alleviating suffering (Donovan, 2011).

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reasonable will and legitimate interests must always be respected. (Catechism of the Catholic Church, 2278) The key principle in this statement is that one does not will to cause death. When a person has an underlying terminal disease, or their heart, or some other organ, cannot work without mechanical assistance, or a therapy being proposed is dangerous, or has little chance of success, then not using that machine or that therapy results in the person dying from the disease or organ failure they already have. The omission allows nature to takes its course. It does not directly kill the person, even though it may contribute to the person dying earlier than if aggressive treatment had been done (Donovan, 2011).

Extraordinary means usually refer to highly specialized, physically difficult, psychologically draining or very expensive measures used in order to delay the imminent death and prolong the life of the dying patient. These extraordinary means no longer correspond to the real situation of the patient, either because they are by now disproportionate to any expected results or because they impose an excessive burden on the patient and his family. Excessive burdensomeness is the genus, and species of such burdensomeness include the treatment's riskiness, its bad side-effects and bad consequences on the life of the person [e.g. it may so disable a person he is no longer able to do his job and support his family; he may have to move to a different climate, leaving home, friends, and so forth]; the excessive pain of the treatment, and excessive expense that would imperil the economic security of the patient, the patient's family, and/or the community. Withholding or withdrawing such treatments is not euthanasia or a choice to kill oneself or another for merciful reasons. One does not judge a life excessively burdensome, but rather, one judges a treatment excessively burdensome. In making this judgment, the "physical and moral resources of the patient" -- his or her "quality of life" in that sense -- can rightly be taken into account (Donovan, 2011). The criterion of usefulness judges a means as useless (in the strict sense) if the benefits it promises are nil, or useless (in a wider sense) if the benefits conferred are insignificant in comparison to the burdens it imposes. (May, 2010).

Withdrawing or Withholding Treatment

There are many factors involved in decisions to limit life-sustaining therapy. From the medical point of view, the 1st requirement is that there is at least acceptance and at best consensus agreement among all the members of the medical team, to limit therapy when hope for recovery is outweighed by burden of the treatment. Prognosis in critical illness is often uncertain. Physicians and families may disagree about how to value a small chance of improvement or to weigh the continuing burdens of treatment. The patients wishes for continuation or discontinuation of treatment are of paramount importance. Withdrawing and withholding treatment are equivalent, ethically and legally, although state evidentiary standards for and cultural and religious beliefs about withdrawing or withholding treatment may vary. (Snyder, 2012). Medical treatment should only be withdrawn or withheld on clinical grounds. Every such decision should be made upon its own merits and must not be made on the basis of either cost or medical convenience. Need for an ICU bed for another patient should not be the reason. Limitation of treatment should be regarded as a formal ICU procedure subject to the same preparation, thought, care, and consent as for any other aspect of care. When patients are admitted to the ICU, there needs to be a clear plan for their management, including definitions of the limits of any invasive interventions. The physician, patient, and/or family jointly define the goals of treatment. (Doyle e al, 2005). Treatments should not be withheld because of the mistaken fear that if they are started, they cannot be withdrawn. This would deny patients potentially beneficial therapies. Instead, a time limited trial of therapy could be used to clarify the patients prognosis. At the end of the trial, a conference to review and revise

Foregoing Extraordinary Means to Prolong the Life of a Dying Patient

Foregoing extraordinary means to sustain life is different from euthanasia on several main points: Unlike euthanasia, foregoing extraordinary means is not intended to cause death. The death that follows from foregoing extraordinary means was not induced or directly caused. The death simply follows from the natural process of dying that is no longer postponed by extraordinary means. Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate. It is the refusal of "over-zealous" treatment. Here one does not will to cause death; one's inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose

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the treatment plan should be held. 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 prevent or resolve these situations by addressing with families feelings of guilt, fear, and concern that the patient may suffer as life support is withdrawn, ensure that all appropriate measures to relieve distress are used, and explain the physicians ethical obligation to follow the patients wishes (Snyder, 2012). Any life-sustaining therapy aimed at maintaining organ function that only prolong death may be withdrawn or withheld. In addition to cardiopulmonary resuscitation (CPR), these include elective intubation, mechanical ventilation, surgery, dialysis, blood transfusions, artificial nutrition and hydration, diagnostic tests, antibiotics, other medications and treatments, as well as future admissions to the hospital or to the intensive care unit (ICU) (Ackermann, 2000).

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Artificial Nutrition and Hydration

Artificial administration of nutrition and fluids is a medical intervention subject to the same principles of decision making as other treatments. Nutrition and hydration, like bathing and changing the patient's position to avoid bedsores, is ordinary care that is owed to the patient. This is true even if it is delivered artificially, as when a baby is bottle-fed or a sick person is tube-fed (Donovan, 2011). The removal of nutrition and hydration from a patient who is still capable of assimilating such provisions regardless of the method provided is immoral and unethical since such removal would cause death through starvation and dehydration. In other words, as long as the patient is still able to digest food and fluids, nutrition and hydration are vital to maintain bodily function (Lignor, 2009). Physicians have difficulty with the decision to initiate or continue artificial nutrition and/or hydration. Food and water are symbols of caring, so withholding artificial nutrition and hydration may be misperceived as neglect. However, nutrition and hydration may be discontinued when they cannot achieve their natural purposes, such as when the body can no longer process them, or, when during the death process they would only prolong the person's suffering. If such is the case, the patient dies of the underlying disease. The question therefore must be asked: "will the withdrawal of nutrition and hydration allow the person to die, or kill the person?" When it will allow a person to die from an underlying condition, rather than

unnecessarily prolonging their suffering, it may be removed. So, for example, in the last hours, even days, of a cancer patient's life, or if a sick person's body is no longer able to process food and water, there is no moral obligation to provide nutrition and hydration. The patient will die of their disease or their organ failure before starvation or dehydration could kill them. However, when the withdrawal of nutrition and hydration, starvation and dehydration, is the foreseeable cause of death and is intended to kill the person, or will be the immediate and direct cause of doing so, quite apart from any disease or failure of their bodies, then to withdraw food and water would be gravely immoral, a grave sin against the natural law and the law of God. However, during the last days of life, patients tend naturally to take in less and less food and fluid. Hunger is rare in the last days of life. Thirst occurs more commonly, but without relation to dehydration, and can usually be controlled by simple measures (e.g., moistening the lips, giving small sips of fluids or small amounts of crushed ice to suck). Enteral feeding should be stopped when the patient can no longer swallow reliably. In most cases, parenteral (IV) fluids should not be given in the last hours of life. Allowing the patient to become slightly dehydrated may prevent or ameliorate many otherwise distressing problems in the last hours. Imminently dying patients may develop fluid overload as their kidneys stop functioning, with peripheral and pulmonary edema; continued administration of intravenous fluids exacerbates these symptoms and may cause substantial distress. Physicians should address these issues with patients and loved ones involved in providing care. (Waller, 1996).

Futile Treatments
Futility refers to the benefit of a particular intervention for a particular patient. With futility, the central question is "Does the intervention have any reasonable prospect of helping this patient?" (Jecker, 1998). In the circumstance that no evidence shows that a specific treatment desired by the patient will provide any medical benefit, the physician is not ethically obliged to provide such treatment (although the physician should be aware of any relevant state law) (Snyder, 2011). Futile interventions are ill advised because they often increase a patient's pain and discomfort in the final days and weeks of life, and because they can expend finite medical resources. Although the ethical requirement to respect patient autonomy entitles a patient to choose from among medically acceptable treatment options (or to reject all options), it does not entitle patients to receive

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comfort/sedation, with the intention of hastening death, is euthanasia and is not acceptable/legal medical practice. Sedation should be provided to all patients, even those who are comatose. The doses needed to control symptoms depend on the neurological status of the patient and presence of drug tolerance (these same drugs are commonly used in routine ICU care). Never make assumptions about what the family understands; describe the procedure in clear, simple terms and answer any questions. Families should be told before-hand the steps of withdrawal and whether or not it is planned/desired to remove the endotracheal tube. In addition, they should be counseled about the use of oxygen and medications for symptom control. Assure them that the patients comfort is of primary concern. Explain that labored breathing and signs of breathlessness may occur, but that they can be managed. Confirm that you will have medication available to manage any discomfort. Ensure they know that the patient will likely need to be kept asleep to control their symptoms and that involuntary moving, noisy or irregular breathing, or gasping do not reflect suffering if the patient is properly sedated or in a coma. After ventilator withdrawal, the family and the nurse should have tissues for extra secretions, and for tears. The family should be encouraged to hold the patient's hand and provide assurances to their loved one. Be prepared to spend additional time with the family discussing questions/concerns. (Von Gunten, 2005).

whatever treatments they ask for. Instead, the obligations of physicians are limited to offering treatments that are consistent with professional standards of care. The ethical authority to render futility judgments rests with the medical profession as a whole, not with individual physicians at the bedside. Thus, futility determinations in specific cases should conform with more general professional standards of care. (Jecker, 1998). The physician need not provide an effort at resuscitation that cannot conceivably restore circulation and breathing, but he or she should help the family to understand and accept this reality. The more common and much more difficult circumstance occurs when treatment offers some small prospect of benefit at a great burden of suffering or financial cost, but the patient or family nevertheless desires it. If the physician and patient (or appropriate surrogate) cannot agree on how to proceed, there is no easy, automatic solution. Consultation with learned colleagues or an ethics consultation may be helpful in ascertaining what interventions have a reasonable balance of burden and benefit. (Snyder, 2012). In some instances, it may be appropriate to continue temporarily to make a futile intervention available in order to assist the patient or family in coming to terms with the gravity of their situation and reaching a point of personal closure. For example, a futile intervention for a terminally ill patient may be continued temporarily in order to allow time for a loved one arriving from another country or place to see the patient for the last time (Jecker, 1998).

Euthanasia, Physician-Assisted Medicalized Killing

Suicide,

and

Ventilator Withdrawal in Patients Expected to Die Discussing ventilator withdrawal to allow death is appropriate once it is decided that further aggressive medical care is incapable of meeting the desired goals of care for a ventilator-dependent patient. All members of the care team should be involved and apprised of the decision-making process and have the opportunity to discuss the plan of care. The most common symptoms related to ventilator withdrawal are breathlessness and anxiety. Opioids and benzodiazepines are the primary medications used. Concerns about unintended hastened death are exaggerated, particularly if established dosing guidelines are followed. There is no medical or ethical justification for withholding sedating medication when death following ventilator withdrawal is the expected goal. However, increasing doses beyond the levels needed to achieve

Euthanasia consists of an act or omission which, of itself or by intention, causes death in order to eliminate suffering. It constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator. The death caused by euthanasia is not part of the natural process of dying of a terminally ill person. Whatever its motives and means, direct euthanasia consists in putting an end to the lives of handicapped, sick, or dying persons. It is morally unacceptable. (Catechism of the Catholic Church, 2277) Euthanasia is killing on request and is defined as a doctor intentionally killing a person by the administration of drugs, at that persons voluntary and competent request. Physician-assisted suicide is defined as a doctor intentionally helping a person to commit suicide by providing drugs for self-administration, at that persons voluntary and competent request (Materstvedt et al, 2003).

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Medicalized killing of a person without the persons consent, whether nonvoluntary (where the person is unable to consent) or involuntary (against the persons will), is not euthanasia: it is murder. Hence, euthanasia can be voluntary only. (Materstvedt et al, 2003)

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Palliative Sedation vs. Euthanasia

Palliative or terminal sedation is the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of otherwise intractable suffering in a manner that is ethically acceptable to the patient, family and health-care providers. Sedation is used in palliative care in several settings: (1) transient sedation for noxious procedures; (2) sedation as part of burn care; (3) sedation used in end of life weaning from ventilator support; (4) sedation in the management of refractory symptoms at the end of life; (5) emergency sedation; (6) respite sedation; (7) sedation for psychological or existential suffering. In palliative or terminal sedation of those imminently dying, the intention is to relieve intolerable suffering; the procedure is to use a sedating drug for symptom control; the successful outcome is the alleviation of distress. In euthanasia, the intention is to kill the patient; the procedure is to administer a lethal drug; the successful outcome is immediate death. In palliative care, mild sedation may be used therapeutically but in this situation it does not adversely affect the patients conscious level or ability to communicate. The use of deeper sedation (which leads to the patient becoming unconscious) should be adopted when mild sedation has been ineffective. Continuous deep sedation could be selected first if: (1) the suffering is intense; (2) the suffering is definitely refractory; (3) death is anticipated within hours or a few days; (4) the patients wish is explicit; and (5) in the setting of an end-of-life catastrophic event such as massive hemorrhage or asphyxia. However, the level of sedation must be reviewed on a regular basis and in general used only temporarily. It is important that the patient is regularly monitored. (Cherny and Radbruch, 2009).

Abuse of palliative sedation occurs when clinicians sedate patients approaching the end of life with the primary goal of hastening the patients death (Onwuteaka-Philipsen et al, 2003; Rietjens et al, 2004; Douglas et al, 2001; Kuhse et al, 1997). This has been called slow euthanasia. Indeed, some physicians administer doses of medication, ostensibly to relieve symptoms, but with a covert intention to hasten death. This may occur by the deliberate use of deep sedation in patients who have no refractory symptoms, or in the deliberate use of doses that far exceed that which is necessary to provide adequate comfort. Excess doses can compromise physiological functions such as spontaneous respiration and hemodynamic stability. These duplicitous practices represent an unacceptable, and often illegal, deviation from normative ethical clinical practice.

The Use of Painkillers That May Shorten the Life of a Terminally-ill Patient
The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable. Palliative care is a special form of disinterested charity. As such it should be encouraged (Catechism of the Catholic Church, 2279) It is licit to relieve pain by narcotics, even when the result is decreased consciousness and a shortening of life, "if no other means exist, and if, in the given circumstances, this does not prevent the carrying out of other religious and moral duties." In such a case, death is not willed or sought, even though for reasonable motives one runs the risk of it: there is simply a desire to ease pain effectively by using the analgesics which medicine provides. (John Paul II, Evangelium Vitae, 65)

Disorders of Consciousness
There are a variety of disorders of impaired consciousness with variable prognoses, including coma, persistent and permanent irreversible vegetative states (wakeful unresponsiveness), and the minimally conscious state (The Multi-Society Task Force on PVS, 1994). Diagnostic clarity in determining the patients brain state by clinicians qualified to make such assessments before making ethical judgments about appropriate care is critical (Fins and Plum, 2004). Goals of care as decided by the patient in advance or by an appropriate surrogate should guide decisions about treatment for these patients as for other patients without decision-making capacity. John Paul II (2004) stated that

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Withholding and Withdrawing Life-Sustaining Treatment

Table 2. Typical Legal and Ethical Concerns Attending Physicians May Have Regarding the Withholding or Withdrawing of Potentially Life-Sustaining Treatments* Are physicians legally required to provide all life-sustaining measures possible? No. To the contrary, patients have a right to refuse any medical treatment, even life-sustaining treatments such as mechanical ventilation, or even artificial hydration and nutrition. Is withdrawal or withholding of treatment equivalent to euthanasia? No. There is a strong general consensus that withdrawal or withholding of treatment is a decision that allows the disease to progress on its natural course. It is not a decision to seek death and end life. Euthanasia actively seeks to end the patient's life. Can the treatment of symptoms constitute euthanasia? No. For patients who have been using opioids for pain, it is very difficult to give such high doses that death is caused or even hastened in the absence of a disease process that is leading to imminent death. Patients tend to sleep off the effect if they receive too much medication. However, in the rare circumstance when opioids might contribute to death, provided the intent was genuinely to treat the symptoms, then opioid use is not euthanasia. Is it illegal to prescribe large doses of opioids to relieve pain, breathlessness or other symptoms? No. Even very large doses of opioids (thousands of milligrams per day) are permitted and appropriate, if the intent and doses given are titrated to the patient's needs. Are you killing the patient when you remove the ventilator and treat the pain? No. The intent and sequence of actions are important, as are the means chosen. If the intent is to secure comfort, not death; if the medications are chosen for and titrated to the patient's symptoms; if the medications are not administered with the primary intent to cause death, then ventilator withdrawal and pain treatment are not euthanasia.

* From Education for Physicians on End-of-Life Care Trainer's Guide, Module 11, withholding, withdrawing therapy. In: Emanuel
LL, von Gunten C J, Ferris FD. Education for physicians on end-of-life care/Institute for Ethics at the American Medical Association. Chicago, IL: EPEC Project, The Robert Wood Johnson Foundation, 1999

the sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his/her confinement to bed. He/she also has the right to appropriate rehabilitative care and to be monitored for clinical signs of eventual recovery.

Clinical Practicalities
Going back to the case presented at the beginning of this article, the attending physician should carefully evaluate the goals of therapy as they relate to TPN. Is TPN likely to offer the patient any benefit? If the patients life expectancy can be prolonged with additional chemotherapy, it may be reasonable to give TPN to allow the patient to enjoy that benefit. If additional chemotherapy offers no substantial increase in quantity or quality of life, TPN could become another burden for the patient without any meaningful benefit, and ought to be withheld. Advance directives should be discussed and signed by terminally-ill patients themselves before an acute crisis. The prognosis of full recovery from mechanical ventilation in this case is poor, particularly as Mrs. S went into cardiorespiratory arrest and was resuscitated after 15 minutes. The approach to the patients request to withhold life-sustaining treatment should start with an evaluation of her decision making capacity. Even though she was awake and alert, the attending physician should carefully probe the reasons for her request, with particular

Discharge of a dying patient who wants to die at home

Sometimes, following sudden realization of a rapid decline, a patient may decide that he/she wants to go home to die. This is consistent with respect for patients autonomy. In these changing circumstances, time can be short and clinicians need to be flexible for this to be possible. Proper discharge care planning, together with the palliative home care team, facilitates safe discharge and access to continuing care support for such patients (Watson et al, 2009).

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attention to making sure she understands the consequences of her decision. If the attending physician were concerned about depression or other mental illness affecting her thinking about this decision, a psychiatry consultation may be requested. The attending physician should ask Mrs. S if she had discussed this with her spouse or family. If her decision making capacity is intact, the attending physician should honor her request, even if the husband deemed otherwise (Braddock, 1998). Post-arrest and cardiopulmonary resuscitation, the family should be convened and the pros and cons of continuation or termination of life-sustaining treatment should be discussed. It should be explained that patients judged to have no chance for recovery of brain function can no longer benefit from being maintained on a mechanical ventilator. All that continuation would achieve in such a case is maintenance of biologic function. In such a case, it would be justifiable to withdraw mechanical ventilation. This is especially so as the patient was competent, and when she was still awake and alert was able to verbally communicate to the attending physicians that she wanted to die with dignity and did not want to be hooked to a respirator. Physician counseling of families is a critical aspect of care for the dying patient who is to be removed from a ventilator. It is important to approach such conversations with compassion for the patient and grieving family. Ideally the family would be involved in the decision to withdraw the ventilator and thus apprised of the goals of care. The family should be assured that the patients comfort remain to be of primary concern and that medications would be given to manage any discomfort prior to, during, and after ventilator withdrawal.

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legal issues, as well as familiarity with practical aspects of implementation

References:
1. Ackermann, R.J. (2000). Withholding and Withdrawing Life-Sustaining Treatment. Am Fam Physician. 62(7):1555-1560. 2. American Coll Physicians.(2001). Living with a serious illness: talking with your doctor when the future is uncertain. Patient Education and Caring: End-of-Life (PEACE) series. Philadelphia. Retrieved April 23, 2012, from the American College of Physicians Web site: www.acponline.org/patients_families/end_of_life_issues/ peace/. 3. Ascension Health (2012). Quality of life. Retrieved April 23, 2012, from http://www.ascensionhealth.org/index.php?option=com_c ontent&view=article&id=197&Itemid=172. 4. Braddock, C.H. (1998). Termination of Life-Sustaining Treatment. Retrieved April 23, 2012 from the University of Washington School of Medicine Web site: Retrieved April 23, 2012 from the University of Washington School of Medicine Web site: http://depts.washington.edu/bioethx/topics/termlife.html 5. Catholic Church. (1997). Catechism of the Catholic Church: Revised in Accordance with the Official Latin Text Promulgated by Pope John Paul II. Vatican City: Libreria Editrice Vaticana. Retrieved April 23, 2012, from the Vatican Web site: http://www.vatican.va/archive/ccc_css/archive/catechism/ p3s2c2a5.htm 6. Cherny NI, Radbruch L, The Board of EAPC. (2009). European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med, 23:581-593. 7. Donovan, C.B. (2011). End-of-Life Decisions. Retrieved April 23, 2012, from the Eternal Word Television Network Web site: http://www.ewtn.com/morals/end-oflife.htm 8. Douglas CD, Kerridge IH, Rainbird KJ, McPhee JR, Hancock L, Spigelman AD. (2001). The intention to hasten death: a survey of attitudes and practices of surgeons in Australia. Med J Aust. 175: 511515. 9. Doyle, D., Hanks, G., MacDonald, N. (2005). Oxford textbook of palliative medicine. Oxford: Oxford University Press 10. Emanuel LL, von Gunten CF, Ferris FF, eds. (1999). Module 11: Withholding and Withdrawing Therapy. The EPEC Curriculum: Education for Physicians on End-of-life Care. Chicago, IL: The EPEC Project. http://www.EPEC.net. 11. Fins JJ, Plum F. (2004). Neurological diagnosis is more than a state of mind: diagnostic clarity and impaired consciousness [Editorial]. Arch Neurol. 61: 1354-5. 12. Jecker, N.S. (1998). Futility. Retrieved April 23, 2012 from the University of Washington School of Medicine Web site: http://depts.washington.edu/bioethx/topics/futil.html

Conclusion
The many advances in medicine during recent decades had saved many people who would simply have been allowed to die in the past. Further, having saved them, many people continue to live for long periods in comatose or semi-conscious states, unable to live without technological assistance of one kind or another. In the wards, doctors would have patients who are receiving treatments or interventions that keep them alive, and the attending physicians face the challenge of helping patients and families decide whether to undergo or forego medical treatments. In some circumstances, these treatments are no longer of benefit, while in others the patient or family no longer want them. Making and implementing decisions about life-sustaining treatments are essential skills for attending physicians. Good care is based on an understanding of the ethical and medico-

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