14.1 ETHICAL CONSIDERATIONS

It is the physician’s duty to preserve life and relieve suffering. These dual obligations sometimes conflict, most frequently at the end of life. The principle of patient autonomy generally requires the physician to respect the decision of a patient or their surrogate decision maker to withhold or withdraw treatment they believe will not help them achieve their goals of care [1]. Life-sustaining treatment by definition serves to prolong quantity of life without reversing the underlying disease process(es) or necessarily improving the quality of life. Because approximately one-third of all deaths in the United States occur in an acute care hospital and 22% of all deaths occur in or subsequent to an ICU admission, it is incumbent upon today’s hospitalist to understand the three ethical principles relating to the withdrawal of life-sustaining treatment [2, 3]:

1. Withholding and withdrawing life support are equivalent. Although clinicians and family members are often psychologically more comfortable withholding treatments than withdrawing them, likely due to the passive nature of the former and the seemingly more active nature of the latter, there is no ethical or legal distinction between the two [1, 4]. As with any medical intervention, the benefits and burdens must be weighed. When a patient has not responded to an adequate trial of a particular intervention, the physician is not obligated to continue [5, 6]. Indeed, continued intervention may only serve to prolong the dying process and potentially exacerbate the patient’s suffering.
   
2. Acknowledging and allowing natural death is ethically and legally distinct from killing. Through numerous legal precedents of the U.S. judicial system—including landmark cases such as Quinlan, Conroy, and Cruzan—the withholding or withdrawal of life-sustaining interventions is consistent with the ethical principles of autonomy and nonmaleficence. In other words, it may be better to not do something rather than risk doing more harm [1, 4]. The concepts of physician-assisted suicide, legally permissible in only two U.S. states (Oregon and Washington), and euthanasia are beyond the context of this discussion.
   
3. The doctrine of double effect. This philosophical and legally recognized principle is used to draw an ethical and moral distinction between an intended consequence of a particular action and a merely foreseen result of an action [4]. The words of former U.S. Supreme Court Justice William Rehnquist perhaps best summarize this doctrine as follows: “It is widely recognized that the provision of pain medication is ethically and professionally acceptable even when the treatment may hasten the patient’s death if the medication is intended to alleviate pain and severe discomfort, not to cause death” [7]. Thus, once it has been decided to pursue comfort as the primary treatment goal, concerns regarding the use of pain and other symptom-alleviating medications become secondary to the primary intent of providing comfort.

14.2 MEDICAL–LEGAL CONSIDERATIONS

In order to alleviate pain and other symptoms at the end of life or during the withdrawal of life-sustaining treatments, it is often necessary to provide large and sometimes rapidly increasing dosages of opioids and other medications. It is critical to clearly express the intent of such orders in verbal communication to the patient’s family and hospital staff and via written documentation in the medical record. This intention is evident when the physician consistently demonstrates ongoing assessment of the patient’s condition along with the titration of medications in accordance with accepted clinical practice [4].