Withdrawing support

Definition

Withdrawing support, or withdrawing life support, refers to stopping or removing various devices or treatments used to sustain vital body processes.

Life support procedures are usually put in place in order to stabilize a patient until he or she can start to breathe, eat and drink, or until his or her heart can start beating normally again. In many cases, when an illness is considered curable or treatable, life support measures are successful in maintaining body processes until the person can continue recovering on their own. At other times, however, life support is considered futile treatment; that is, the patient has an incurable disease or will never recover full functioning, and further treatment is considered useless. At that point, the decision is usually made to withhold life support (not starting it in the first place) or withdrawing it (stopping it once it has been started). Although at one time doctors made a distinction between withholding and withdrawing life support, as of the early 2000s most lawyers and ethicists believe that it is appropriate to try life support if there is even a small chance that it will help the patient. If it becomes clear after a few days that the treatment is not helping, then the doctor can withdraw it without feeling that he or she is causing the patient's death.

Description

Dramatic cases involving withdrawal of life support often receive wide publicity in the media, and many people think that withdrawal of life support is therefore unusual. A Harris survey conducted in 2005, however, found that 28 percent of the adults surveyed had experienced the death of a close friend or family member within the past 10 years who had been on life support before death. Of these deaths, two-thirds had happened after life support was withdrawn; only 34 percent of the patients had died while they were still on life support systems. By extending these figures to the total adult population of the United States, the authors of the survey concluded that “death following the withdrawal of life support happens millions of times [in the United States] every year. This is neither uncommon nor unusual.”

There are three major systems or procedures commonly used in life support: artificial nutrition and hydration; cardiopulmonary resuscitation (CPR); and mechanical ventilation.

Artificial nutrition and hydration

Artificial nutrition and hydration refers to giving a patient who cannot eat or drink normally a balanced combination of fluids and nutrients through a tube placed directly into the stomach or the upper intestine, or a vein. This form of nutrition is commonly called tube feeding.

When tube feeding is withdrawn or withheld, the patient dies of dehydration rather than starvation, usually within 5–12 days, as the body can survive longer without food than without fluids. According to doctors, dehydration is not a painful process as long as the patient's mouth is kept moist, because the mouth is the only part of the body that can perceive thirst.

Cardiopulmonary resuscitation

Cardiopulmonary resuscitation is a series of procedures undertaken to provide artificial blood circulation and artificial respiration until a patient whose heart has stopped beating (or who has stopped breathing) regains a normal heartbeat. It is essential to maintain a flow of blood to the brain, because the brain suffers damage if blood flow is interrupted for 4 minutes and may suffer irreversible damage after 7 minutes. For this reason CPR is usually effective only within 7 minutes of cardiac arrest, although it can still double or triple the patient's chances of survival.

Outside a hospital, CPR consists of a series of chest compressions and mouth-to-mouth resuscitation performed until emergency personnel arrive. A defibrillator, or device that delivers a dose of electrical to the heart, is usually needed to restart normal heartbeat. Many emergency vehicles carry defibrillators to use when needed.

Stopping CPR is usually not a controversial decision, particularly if some time has passed since the patient's heart stopped and brain damage has almost certainly occurred.

Mechanical ventilation

Mechanical ventilation is a type of life support in which a machine called a ventilator or respirator is used to force air into the patient's lungs through a tube inserted into the nose or mouth. The tube extends down into the patient's trachea or windpipe. Mechanical ventilation is used to supply oxygen to the body until the patient can breathe on their own again, but it is also used in cases of incurable disease or damage to the central nervous system to prolong life until some other body system fails.

To withdraw this type of life support, the tube is usually removed from the patient's mouth or nose before death; this is called extubation. Before or during extubation, the patient is usually given a combination of opioids (painkillers) and benzodiazepines (tranquilizers) to minimize discomfort and prevent coughing or seizures. In some cases the respirator is adjusted gradually to a series of lower settings while in others, mechanical ventilation is stopped at once.

Viewpoints

Withdrawal of life support is controversial because it raises fundamental and disturbing questions about the nature and value of human life as well as control over one's body at the end of life. It is one of the primary reasons for making advance directives, which are written statements of personal preferences regarding medical care at the end of life and authorizing another person to make decisions about health care in one's stead. Many people would prefer not to be kept alive for prolonged periods of time by artificial nutrition or mechanical ventilation, while others are distressed by the possibility of being denied life support measures.

KEY TERMS

Advance directive —A document in which a person describes their wishes regarding medical treatment if they are incapacitated and names another person (proxy) to direct their care.

Cardiac arrest —The medical term for the failure of the heart to contract normally and blood circulation to stop abruptly as a result.

Cardiopulmonary resuscitation (CPR) —The name for a group of treatments, including drugs and electric shocks, intended to clear the passageways to the lungs and restart the heart.

Defibrillator —A machine used by emergency health care personnel to deliver an electric shock to heart muscle in order to restore normal heart beat.

Ethicist —A person who studies and writes about moral principles and questions involving good and evil or human duties and obligations.

Extubation —The removal of the tube that connects a patient to a ventilator.

Futile care —Medical care that is useless or highly unlikely to produce a good outcome.

Prognosis —Prediction of the course of a disease and the patient's chances of recovery.

Ventilator —A machine that moves breathable air in and out of the lungs of a person who cannot breathe on their own.

Advance directives do not, however, always resolve the question of withdrawing support in actual situations. In some cases the patient's wishes are not followed, either because family members disregard them or disagree among themselves, or because there has been poor communication between family members and staff. In 95 percent of cases, according to one study, the patient is not conscious or able to communicate clearly. Sometimes it is not clear even to the patient's doctors whether further treatment is futile, or whether the patient has a chance, however small, to improve.

Several doctors offer the following recommendations to help family members and health care professionals resolve disagreements and deal with guilt feelings about withdrawing life support:

• Doctors and nurses should tell family members about the patient's prognosis in clear and understandable language and in a timely fashion.
• They should be available to family members to answer any questions that may arise rather than avoiding the family out of their own discomfort.
• The patient should be kept comfortable and his or her physical symptoms controlled.
• The decision to withdraw support should not be made by only one person, even a family member; it should represent a consensus.
• Health care professionals should always involve the family in decisions about withdrawing support rather than doing it without consultation because they consider further care futile.
• The family should be encouraged to remain with the patient when support is withdrawn and to have a clergyperson or other spiritual leader present for religious end-of-life rituals.

Resources

BOOKS

Beers, Mark H., M. D., and Thomas V. Jones, MD. Merck Manual of Geriatrics, 3rd ed., Chapter 13, “Care of the Dying Patient.” Whitehouse Station, NJ: Merck, 2005.

Caplan, Arthur, James J. McCartney, and Dominic A. Sisti. The Case of Terri Schiavo: Ethics at the End of Life. Amherst, NY: Prometheus Books, 2006.

Wicclair, Marc R. Ethics and the Elderly. New York: Oxford University Press, 1993.

PERIODICALS

Mayer, Stephan A., and Sharon B. Kossoff. “Withdrawal of Life Support in the Neurological Intensive Care Unit.” Neurology 52 (1999): 1602.

Orr, Robert D., M.D., and Gilbert Meilaender. “Ethics and Life's Ending.” First Things, August/September 2004. Available online at http://www.firstthings.com/article.php3?id_article=371&var_recherche=%22life+support%22 [cited February 23, 2008].

Prendergast, Thomas, M.D., and Kathleen Puntillo, R.N. “Withdrawal of Life Support: Intensive Caring at the End of Life.” Journal of the American Medical Association 288 (December 4, 2002): 2732–2740. Available online at http://cms.clevelandclinic.org/ccfpulmonary/documents/journals/Withdrawal%20of%20Life% 20Support%20Dec.%202002.pdf [cited February 23, 2008].

Way, Jenny, Anthony Back, and J. Randall Curtis. “Withdrawing Life Support and Resolution of Conflict with Families.” British Medical Journal 325 (December 7, 2002): 1342–1345. Available online at http://cms.clevelandclinic.org/ccfpulmonary/documents/journals/Withdrawing%20Life%20Support%20and%20Resolution%20of%20Conflict%20with%20Families%20Dec.%202002.pdf [cited February 24, 2008].

OTHER

Cleveland Clinic. Understanding Life Support Measures. Cleveland, OH: Cleveland Clinic, 2006. Available online at http://www.clevelandclinic.org/health/health-info/docs/3800/3888.asp?index=12362 [cited February 24, 2008].

Harris Poll. “Withdrawal of Life Support Systems Is More Common Than Public May Think.” Harris Interactive, April 21, 2005. Available online at http://www.harrisinteractive.com/harris_poll/index.asp?PID=560 [cited February 23, 2008].

Johns Hopkins Hospital. “Procedure for Withdrawal of Life Support in the MICU/ICP.” The Johns Hopkins Hospital Medical Nursing Service Standards of Care Manual. Baltimore, MD: The Johns Hopkins Hospital, 2001. Available online at http://www.aacn.org/PalCare/pdfs/withdrawal_procedure_jhopkins.pdf [cited February 23, 2008].

ORGANIZATIONS

American Medical Association (AMA) Institute for Ethics, 515 N. State Street, Chicago, IL, 60610, (800) 621-8335, http://www.ama-assn.org/ama/pub/category/2558.html.

The Hastings Center, 21 Malcolm Gordon Road, Garrison, NY, 10524, (845) 424-4040, (845) 424-4545, mail@thehastingscenter.org, http://www.thehastingscenter.org/default.asp.

The President's Council on Bioethics, 1425 New York Avenue, NW, Suite C100, Washington, DC, 20005, (202) 296-4669, info@bioethics.gov, http://www.bioethics.gov/.

Rebecca J. Frey Ph.D.