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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
    Important Questions about Withholding/Withdrawing Treatment

    Patient Goals Need Translation Into Treatment
    Physician's Role is Essential
    Common Questions and Concerns

    Patient Goals Need Translation into Treatment

    Even with advance directives in place, it is not always clear how to translate general goals or preferences into treatment of the present medical conditions

    Critical that physicians have the knowledge and skills necessary for discussions, negotiations, and implementation of decisions related to life-sustaining treatments

    Legislation and policies regarding withholding or withdrawing life-sustaining treatment

    • US states
    • Local health care institutions
    • Protection of:
      • Patient rights
      • Risk management
    • Often goal is "life at all costs"
      • Default mode
      • Most state statutes require emergency medical technicians to provide all resuscitative and life-prolonging treatments unless a physician order specifies otherwise
    • However, if the appropriate goals are other than "life at all costs," then the physician needs to write specific orders to accomplish the intended goals

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    Physician's Role is Essential

    • Only member of the health care team who can ensure appropriate care if the goals are other than "life at all costs"
    • Responsible to ensure that the patient's wishes (or parents' if the patient is a child) are followed across care settings
      • Without physician supervision, patients are transferred to the acute-care setting where life-sustaining measures are administered because the appropriate treatment plan and physician's orders have not been completed and paced in the patients' chart

      • Also, physician orders may not transfer across settings
      Evidence
      The SUPPORT study demonstrated that the majority of patients in intensive care unit settings die without attention to issues of life-sustaining treatment. Many of these patients have undergone some form of invasive medical treatment against their previously stated wishes
      Another study demonstrated that fewer than 25% of advance directive orders were carried from the nursing home to the acute-care hospital

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    Common Questions and Concerns

    • Are physicians legally required to provide all life-sustaining measures possible?
      • No
      • In contrast, patients have a right to refuse any medical treatment, even life-sustaining treatments
    • Is withdrawal or withholding euthanasia?
      • Strong general consensus that withdrawal or withholding of treatment is a decision/action that allows the disease to progress on its natural course

      • It is not a decision/action actively to seek death

      • Euthanasia actively seeks to end the patient's life
    • Are you killing the patient when you remove the ventilator or treat pain?
      • Intent and the sequence of actions are important, as are the means chosen.

      • Ventilator withdrawal and pain treatment are not euthanasia if:
        • Intent is to secure comfort, not death
        • Medications are chosen for (and triturated to) the patient’s symptoms as ventilator weaning proceed
        • Medications are not administered with the primary intent to cause death

      • Usually, actions intended to provide comfort and freedom from unwanted intervention result in a slower progression to death than do actions intended to euthanize
    • Can the treatment of symptoms constitute euthanasia?
      • For patients who have been using opioids for pain, it is in fact very hard to give such high doses of opioids that death is caused (or even hastened) in the absence of a disease process that is leading to imminent death, particularly if accepted dosing guidelines are adhered to

      • Patients tend to sleep off the effect if they get too much medication

      • However, for the rare circumstances when opioids might contribute to death, provided the intent was genuinely to treat the symptoms, then opioid use is not euthanasia

      • Be careful to avoid the rationale that says, "death is the treatment!"

      • Symptom treatment alleviates symptoms; it does not intentionally cause death
    • Is the use of substantial doses of opioids euthanasia?
      • Even very large doses of opioids are both permitted and appropriate

      • Intent and doses given are titrated to the patient’s needs
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