Withholding and Withdrawing of Life Support

As a result of the growth and evolution of health care in today's society, health care professionals and the general public are facing difficult decisions. Patients receiving health care often worry that if they become incompetent and unable to express their wishes, they may be subjected to medical interventions that sustain their existence, but not necessarily their quality of life. Often in spite of all interventions, a situation of futility is faced. These situations raise challenges for health care professionals, the patients and their families, and may impact their moral, ethical and religious beliefs.

This position statement on withholding or withdrawing of life support is based on certain ethical beliefs and principles:

  • Patients have the right to be autonomous when making decisions about their own health care. Autonomy refers to the right to control what happens to one's self and to make one's own decisions free of constraints.
  • Each patient's health decisions must be made on an individual basis.
  • Health care professionals should only act in the way that would best benefit the patient.
  • Life support refers to the provision of any or all of the following: assisted ventilation, inotropic support, and all or any mechanism utilized to maintain and/or support the life of a deteriorating patient. The removal of fluids and/or nutrition may also be discussed on an individual basis.
The Canadian Association of Critical Care Nurses (CACCN) believes that critical care nurses play an integral part in how the decision making processes regarding withholding or withdrawing of life support occur for the critically ill. The Association believes that every person is autonomous and has the right to withhold or withdraw treatment when an underlying condition will cause their ultimate death.

CACCN, therefore, feels that the following factors are essential for nursing practice:

  • Every patient has the right to information about prognosis and the futility of interventions, and a suitable course of action regarding the withdrawal or withholding of life support.
  • Consistent information must be provided in order to enhance mutual trust and diminish the possibility of conflict.
  • Actions regarding withdrawal or withholding of life support should be recommended by the health care team using a multi_disciplinary approach.
  • Patient must be involved in all decisions regarding their care if possible.
  • The critical care nurse must participate in the ongoing assessment of the patients' ability to make their own decisions regarding their own health plan.
  • Critical care nurses support the development of Advance Directives prior to entry into the health care system. If patients are unable to partake in the decision making process then their Advance Directive will take effect.
  • When patients do not have an Advance Directive regarding their care, their health proxy will then be involved in the decisions regarding their care.
  • When the wishes of an incompetent patient are not known, then best judgment should be made with consideration for quality of life.

CACCN believes that healthcare institutions and provincial associations have a responsibility in directing the process of withdrawing or withholding life support treatments. Policies and procedures surrounding this issue must be developed to support the critical care nurse in this situation. These policies should include:

  • educational opportunities to prepare nurses for withdrawal or withholding of life support. The shift from acute care to palliative care should encompass more in depth teaching of: communication skills focusing on the emotions exhibited by the family and the dying; recognizing the physical characteristics and behaviors of the dying; and knowing the resources available to give comfort and dignity.
  • mechanisms to relieve a critical care nurse from duties that may breach their personal beliefs.
  • a process to deal with conflict resolution between family members or significant others and the health care team when dealing with decision making issues around withdrawal and withholding of life support.
  • on-site debriefings or counseling to support the critical care nurse when difficult situations are encountered.

References

American Association of Critical_Care Nurses.(1990) Position Statement on Withholding and/or Withdrawing Life_Sustaining Treatment. Aliso Viejo, California, USA.

Canadian Association of Critical Care Nurses. (1999) Advance Directives Position Statement. London, Ontario, Canada.

Canadian Critical Care Society. (1997) Withholding or Withdrawal of Life Support. Position Paper on Withholding and Withdrawal of Life Support. _ Unpublished.

Canadian Healthcare Association, Canadian Medical Association, Canadian Nurses Association and the Catholic Health Association of Canada. (1999) Joint Statement on Resuscitative Interventions.

Campbell, M.L., Hoyt, J.W., and Nelson, L.J. (1994) Health Care Ethics Forum '94: Perspectives on Withholding and Withdrawal of Life_Support. AACN. 5(3), 353_359.

Daly, B.J., Newlon, B., and Langdon, T. (1993) Withdrawal of Mechanical Ventilation: Ethical Principles and Guidelines for Terminal Weaning. American Journal of Critical Care. 2(3), 217_223.

Danis, M., Federman, D., Fins, J., Fox, E., Kastenbaum, B., Lanken, P., Long, K., Lowerstein, E., Lynn, J., Rouse, F., Tulsky, J. (1999) Incorporating Palliative Care into Critical Care Education: Principles, Challenges, and Opportunities. Critical Care Medicine. 27(9), 2005_2012.

Faber_Langendoen, K. (1994) The Clinical Management of Dying Patients Receiving Mechanical Ventilation: A Survey of Physician Practice. Chest. 106(3), 880_887.

Gostin, L.O. (1997) Deciding Life and Death in the Courtroom. JAMA. 278(18), 1523_1528.

Jones, T. and FitzGerald, M. (1998) Withdrawal of Life Support Treatment: The Experience of Critical Care Nurses. Australian Critical Care. 11(4), 117_121.

Keenan, S.P., Busche, K.D., Chen, L.M., Esmail, R., Inman, K.J., and Sibbald, W.J. (1998) Withdrawal and Withholding of Life Support in the Intensive Care Unit: A Comparison of Teaching and Community Hospitals. Critical Care Medicine. 26(2), 245_251.

Luce, J.M. (1991) Withholding and Withdrawing Life Support from the Critically Ill: How Does it Work in Clinical Practice? Respiratory Care. 36(5), 417_426.

Luce, J.M. and Fink, C. (1992) Communicating with Families about Withholding and Withdrawal of Life Support. Chest. 101(5), 1185_1186.

Prendergast, T., Classens, M. and Luce, J. (1998) A National Survey of End_Of_Life Care for Critically Ill Patients. American Journal of Respiratory Critical Care Medicine. 158, 1163_1167.

Senate of Canada. (1995) Of Life and Death: Report of the Special Senate Committee on Euthanasia and Assisted Suicide. Minister of Supply and Services Canada.

Walter, S., Cook, D., Guyatt, G., Spanier, A., Jaeschke, R., Todd, T., Streiner, D. (1998) Confidence in Life Support Decisions in the Intensive Care Unit: A Survey of Healthcare Workers. Critical Care Medicine. 26(1), 44_49.

Wilson, W.C., Smedira, N.G., Fink, C., McDowell, J.A., Luce, J.M. (1992) Ordering and Administration of Sedatives and Analgesics during the Withholding and Withdrawal of Life Support from Critically Ill Patients. JAMA 267.