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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 11: Withholding/Withdrawing Treatment
    How to Discuss Withholding or Withdrawing Treatment

    8-Step Protocol
    Informed Consent
    Three Applications

    8-Step Protocol to Discuss Withholding or Withdrawing Therapy

    Reasonable physicians may disagree about the extent to which specific treatment preferences ought to be discussed, if such treatment will not help achieve the overall goals. As a rule, the discussion of general goals of care should precede the discussion of specific treatment preferences

    The physician usually conducts discussions of treatment preferences. Other appropriate members of the health care team may enhance the discussion and prevent subsequent conflict within the team. They will have additional time to carry on the dialogue with the patient and family. The team will also be able to provide valuable emotional support to the patient, family, and each other

    Even though other members of the health care team participate and/or conduct the discussion, implementation of any decision requires a physician’s order. The attending physician must sign the documentation and assume full responsibility for its accuracy

      1. Be Familiar With Policies and Statutes
      • Policies of institution and pertinent statutes where they practice

      • Most states leave specific treatment decisions to be decided between patient and physician

      • Each institution will have its own policies, and may have developed standard forms regarding life-sustaining treatment
      2. Appropriate Setting for Discussion
      3. Ask Patient and Family What They Understand
      4. Discuss General Goals of Care
      • Determine or reconfirm general goals of care

      • Examples are:

        • "Can we review our overall goals for your care?"
        • " Let me tell you what I understand you want as we plan your care"

      • Once general goals confirmed, specific life-sustaining treatment preferences can be discussed
      5. Establish Context for the Discussion
      • Classic misstatement on the part of well-meaning physicians is, "Do you want us to do everything?"

      • This highly euphemistic and misleading question fails to acknowledge context

        • When are we talking about?

        • Today, when the patient is quite healthy, or at the very end of his or her life when facing death?

        • "Everything" is much too broad and easily misinterpreted by families, especially when they feel "everything" has not, in fact, been done
      6. Discuss Specific Treatment Preferences
      • Use language that the patient will understand (use a medically skilled translator if necessary)

      • Give information in small pieces

      • Reinforce context in which the decisions will apply

      • Stop frequently to check for reactions, to ask for questions, and to clarify misunderstandings

      • Concerns about discussion of specific treatments

        • Reasonable physicians may argue that it is unnecessary and potentially confusing to ask patients and families to decide about specific treatment preferences

        • Patients ill-served, if physicians feel that they must offer all possible therapies from which patients and families choose, as though they were choosing items from a menu in a restaurant

        • Nonetheless, often useful to discuss and recommend withholding or withdrawing specific treatments in light of the general or overall goals previously been established
      7. Respond to Emotions
      • During these discussions, respond to patient and family anxiety

      • Acknowledge emotional content

      • Patients, families, and surrogates may be profoundly disturbed by subject matter being discussed

      • Parents, if the patient is a child, are likely to be very emotional and need support from the physician and other members of the health care team

      • If a physician finds that emotions are too challenging, ask other colleagues and/or members of the health care team to assist
      8. Establish and Implement the Plan
      • Next steps may be as simple as planning to discuss the subject again at the next visit, or convening a family meeting to further discuss the proposed treatment plan

      • They may be as complex as organizing nursing, social work, and chaplaincy intervention

      • Discuss treatment plans with other health care professionals so that the plans may be carried out in a straightforward and organized fashion

      • Write appropriate orders, document discussion in the medical record and talk about the plan with other members of the health care team

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    Informed Consent

    Informed consent is a fundamental ethical principle that underlies contemporary medical care. Patients (parents if the patient is a child) deserve a clear, complete understanding of all therapies that are being proposed for them. Some will want to know all the details. Others will prefer not to know anything.

    Be prepared to describe in simple, neutral terms the aspects of each life-sustaining treatment in a manner that conforms to the principles of informed consent (see Module 8: Sudden Illness):

    • The problem the treatment would address
    • What is involved in the treatment/procedure
    • What is likely to happen if the patient decides not to have the treatment
    • The benefits of the treatment
    • The burdens of the treatment

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    Three Applications
     
    Example 1: Artificial Feeding and Hydration
    Example 2: Ventilator Withdrawal
    Example 3: Cardiopulmonary Resuscitation (CPR)

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