PROCEDURE 138 • Withholding life-sustaining therapy (LST) is defined as “the considered decision not to institute a medically appropriate and potentially beneficial therapy, with the understanding that the patients will probably die without the therapy in question.”10 • Withdrawal of LST is defined as “the cessation and removal of an ongoing medical therapy with the explicit intent not to substitute an equivalent alternative treatment; it is fully anticipated that the patient will die following the change in therapy.”10 • Knowledge of state regulations, and hospital policies or procedures, regarding end-of-life decision making is essential. • Hospitals should have policies that direct the process to withhold and withdraw LST. • As much information as possible should be obtained from the patient regarding preferences about LST. • If the patient is unable to communicate or chooses not to communicate, information should be obtained from the patient’s designated surrogate, family, or healthcare providers regarding the patient’s desired wishes about LST. This information may be ascertained from an advance directive or from verbal conversations with the surrogate, family, friends, or healthcare providers. • Advance directives may exist in the form of a living will or a healthcare proxy. • Some patients have letters or other informal documents in which they convey their preferences for factors that should affect decision making and identify someone who can represent their wishes in decision making. • Patients have a moral and legal right and responsibility to make decisions about their healthcare and the use of LST. • Decision-making capacity is determined by an individual’s ability to2: • If a patient no longer has decision-making capacity, the patient’s preferences should be represented by the patient’s healthcare proxy. The ideal proxy, even if not specified within a legal framework, is the person who can represent the patient’s wishes, not the surrogate’s. That is, decisions made by the healthcare proxy or surrogate should be based on the patient’s previously stated wishes or, if there were no specific statements on presumed preferences, based on lifestyle and prior choices. • Usually the patient’s family is involved in the process of withholding and withdrawing LST. On occasion, the patient prefers that the family not be involved. If the patient does not want the family to be involved, the healthcare team should work with the patient to identify another person who can serve as the healthcare proxy or surrogate in the event that the patient loses decision-making capacity. • Dialogue regarding end-of-life care should be comprehensive. Discussions should include the healthcare team, the patient, and the patient’s family. Discussions should include what treatments are going to be withheld or withdrawn and should focus on patient wishes and medically appropriate goals of care. If the goal of care is a peaceful death, then all therapies that do not contribute toward this goal should be considered for discontinuation, including cessation of vasoactive agents, ventilatory therapy, assist devices, implantable cardioverter-defibrillator therapy, intravenous fluids, nutrition, laboratory studies, radiographs, extubation, etc. • Therapies that support the goal of a peaceful death should be continued, such as administration of analgesia to promote comfort and anxiolytics to decrease anxiety. • Patient comfort should also be promoted by ensuring a comfortable position, frequent skin and mouth care, and interventions to relieve signs and symptoms of distress. • Families need to be supported throughout the end-of-life decision-making process. • Families should be encouraged to say final goodbyes and to be present should they desire during the dying process. • Patients, families, and healthcare providers often have different values. • Healthcare providers are responsible for knowing how their personal beliefs affect their interactions with patients, families, and other healthcare providers. • Patients and their families should be actively involved in all healthcare decisions, including end-of-life decisions (unless the patient requests that family members not be involved; see previous discussion). • Family members involved in end-of-life decision making should be guided by their knowledge of what the patient wants or would want. • If a critical care nurse cannot support the patient and family in the process of withholding or withdrawing LST, the critical care nurse should proceed through the appropriate channels to transfer care to another critical care nurse. • It is recommended that paralyzing agents are discontinued and cleared from the patient’s body before withdrawal of LST.13 • Maintenance of patient dignity and comfort is essential at all times, and especially at the end of life. • Opioid administration to treat pain rarely causes respiratory depression when carefully titrated to a patient’s distress.3,7
Withholding and Withdrawing Life-Sustaining Therapy
PREREQUISITE NURSING KNOWLEDGE
A living will is a document that identifies treatments a patient would or would not want under specific end-of-life situations. Most are specific to terminal illness, permanent state of unconsciousness, or persistent vegetative state.
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138: Withholding and Withdrawing Life-Sustaining Therapy
