WITHDRAWAL OF THERAPY

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WITHDRAWAL OF THERAPY

• By J.A.AL-ATA
• CONSULTANT ASSISTANT PROFESSOR OF PEDIATRIC
  CARDIOLOGY
• CHAIRMAN, BIO-ETHICS COMMITTEE KFSH-RC JED.

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DEFINITION

• Withdrawal of advanced life support (e.g.
  mechanical ventilation) when continued ICU care
  becomes futile or when
  brain death is established.
• However, a narrow definition of futility in this
  situation is the key, since the concept of
  futility could lead to inappropriate decisions.
• It is best to consider a situation futile when
  the patient is terminally ill, the condition is
  irreversible, and death is imminent.

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IMPORTANT POINTS

• The patient is always the key source of authority
  in these decisions.

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CONT

• The most important ingredient in end-of-life
  decision making is effective communication.

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CONT

• It is important to try to ascertain what the
  patient thought about quality-of-life values
  before surrogate decisions can be made on the
  patient's behalf.

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CONT

• The concepts of
• beneficence, nonmaleficence, autonomy, and
  justice are the foundation of ethical decision
  making.
• Treatment is not mandatory.

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IMPLICATIONS OF AUTONOMY

• Competent ( MENTAL , AGE , AUTONOMY , INFORMED )
  patients have the right to refuse treatment
• Patient guardian does not have the right to
  refuse treatment in non-futile situation in which
  refusal of treatment will significantly harm the
  patient.

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CONT

• Studies showed poor agreement between patients
  and surrogates suggesting that substituted
  judgment is not an accurate tool to make
  end-of-life decisions.
• Islamically and probably in other faiths a
  patient is encouraged to seek and accept
  treatment leading to cure or substantial
  improvement or preventing significant harm.

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THE WITHDRAWAL PROCESS

• Establishing the futile situation and/ or brain
  death.

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BRAIN DEATH CRIETERIA

• Deep coma with cessation of respiration.
• Irreversible diagnosed brain or brain stem injury
  for which there is no cure or palliation.
• No cause for transient coma (e.g. hypoglycemia or
  hypothermia or sedative drugs----etc.
• Evidence of no brain stem function
• Enough time
• Confirmatory tests

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CONT

• OR , a confirmed futile state judged at least by
  two consultant physicians.

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CONT

• Proper communication between treating physicians,
  nursing, bio-ethics to gather information about
  the medical,social,religious
  cultural,emotional, and legal situation.

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CONT

• Meeting the concerned family members or
  guardians
• Showing empathy,concern.
• Aiming at explaining the state till well
  understood at reaching a gradual thoughtful
  decision with them.
• Give NEEDED time
• Act truly as the patient and family advocate.

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CONT

• If the decision is made, document in the chart
  and implement in a timely manner.
• If there is opposition allow time for
  reconsideration.
• explore your alternatives
• Avoid confrontation and do not wave with
  legislative empowerment you have early.

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CONT

• Support the family and attend to their wishes and
  needs
• Direct them (if ok) to spend more time with the
  patient and attend to his or her non-medical
  current needs
• Involve the Imam or chaplan

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CONT

• Better to wean from the vent. rapidly than to
  stop it at once
• Comfort,comfort,
• NO pain (avoid over sedation)
• Oxygen
• Hydration
• Maintaining blood glucose not necessarily
  nutrition
• Quiet , private environment.

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CONT

• DONT FALL IN THE TRAP OF EUTHANASIA, ASSISTED
  SUICIDE
• MODIFY PLANS AS CHANGES COME.

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TIPS TO SUCCESSFUL THERAPY WITHDRAWAL

• Discuss issues early with the patient and get to
  his or her wishes.
• Have good rapport with patient and family.
• Evaluate your patient properly before embarking
  on a heroic management plan.

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Situations in which CPR should be performed

• People likely to benefit from CPR should be given
  this treatment if the need arises, unless they
  have specifically rejected it.
• People for whom the benefit of CPR is uncertain
  or unlikely should be given this treatment if the
  need arises, unless they have specifically
  rejected it. CPR should be initiated until the
  patient's condition has been assessed.

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Situations in which CPR should not be performed

• People who have rejected CPR and those who almost
  certainly will not benefit from it should not be
  given this treatment if an arrest occurs.

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Review of CPR decisions

• In the following circumstances review of
  decisions should be undertaken immediately
• If a competent person (or proxy) changes his or
  her decision about resuscitation.
• If there is a significant, unexpected change in a
  person's condition.

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CONT

• A decision not to initiate CPR does not imply the
  withholding or withdrawing of any other treatment
  or intervention.
• A person who does not receive CPR should receive
  all other appropriate treatments, including
  palliative care, for his or her physical, mental
  and spiritual comfort.

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THANK YOU