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  • 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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    Site Index
    Back to Module 11: Withholding/Withdrawing Treatment
    Introduction to Withholding/Withdrawing Treatment

    Introduction to Withholding/Withdrawing Treatment
    Physician's Role
    Life-Sustaining Treatments
    Objectives of this Module

    Introduction to Withholding/Withdrawing Treatment

    The withholding and withdrawing of life-sustaining therapies is ethical and medically appropriate in some circumstances. Facilitating decision-making and implementing decisions about life-sustaining treatments are essential skills for physicians. Physicians need to develop facility with general aspects of the subject, as well as specific skills and approaches. Impediments to good care include misconceptions about legal and ethical issues, as well as unfamiliarity with the practical aspects of implementation.


    Physician's Role

    The physician plays an essential role in defining and implementing the medical care plan, and providing continuity of care as the goals evolve and change over time.

    The physician will often take the lead in initiating discussions about life-sustaining treatment, educating patients and families, helping them deliberate, and making recommendations about the treatment plan.

    Specific elements of the physician's role:

    • Help
      • Patient and family elucidate their own values
      • Patient and family decide about life-sustaining treatments
      • Dispel misconceptions
        • About legal issues and ethical concerns
        • Unfamiliarity with practical aspects of withdrawing or withholding therapy
    • Understand patient goals for care
    • Facilitate decisions, reassess regularly
    • Discuss alternatives, including palliative and hospice care
    • Document preferences and put in place corresponding medical orders
    • Involve and inform other members of the health care team
    • Assure that the patient's comfort is a primary concern
    • Assure that the patient will not be abandoned no matter what the decision


    Life-Sustaining Treatments

    There is a wide range of life-sustaining treatments that might be considered by an individual patient and family. These include cardiopulmonary resuscitation (CPR), elective intubation and mechanical ventilation, surgery, dialysis, blood transfusions or blood products, artificial nutrition and hydration, diagnostic tests, antibiotics, other medications and treatments, and future hospital or ICU admissions.

    After determining the general goals of care, discuss each specific treatment with your patients and families, as appropriate. At a minimum, try to discuss an invasive and a noninvasive intervention to get a general idea of a patient’s priorities for treatment. Decisions about surgery and antibiotics are often strongly predictive of other invasive and noninvasive decisions respectively.

    • Cardiopulmonary resuscitation (CPR)
    • Elective intubation and mechanical ventilation
    • Surgery
    • Dialysis
    • Blood transfusions or blood products
    • Artificial nutrition and hydration
    • Diagnostic tests
    • Antibiotics
    • Other medications and treatments
    • Future hospital or ICU admissions


    Objectives of this Module

    • Know the principles for withholding or withdrawing therapy
    • Apply these principles to the withholding or withdrawal of:
      • Artificial feeding and hydration
      • Ventilation
      • Cardiopulmonary resuscitation
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