Life Sustaining Treatment – An Overview
Keywords- Life, Sustaining, Treatment
Author: Lavanya Murali
Life Sustaining Treatment
Life Sustaining Treatment is any treatment that serves to prolong life without reversing the underlying medical condition. Examples of this are CPR, mechanical ventilation, hemodialysis, left ventricular assist devices, antibiotics, artificial nutrition and hydration. Physicians often encounter patients of all ages with terminal illnesses. So termination of life support is an important intervention that every physician needs to be aware of. Any patient who has reached an ‘end-of-life’ stage and consenting to it would qualify for its initiation.
End-of-Life Patients
An “end-of-life” patient has a life expectancy of 12 months or less and physicians must be well versed in end-of-life care. They should consider the comfort measures in the back of their mind while treating severely ill patients; who are admitted to a hospital or come in for outpatient consultations. This is especially important while treating acutely sick patients with multiple organ failure. Including those in respiratory failure on mechanical ventilation or patients who are diagnosed with advanced-stage cancer or neurodegenerative diseases.
Patients who are nearing their death should be informed of the goals of care and should be asked about their preferences for their end-of-life care. This needs to be dealt with in a sensitive, empathetic manner. Make sure to keep in mind any cultural or religious differences that might exist; and provide realistic expectations and honest information. It is preferable to communicate this directly to the patient. But if not possible due to various medical conditions; the legal surrogate of the patient must be provided with the information.
Legal Status of Surrogate
The legal status of the surrogate must be confirmed before engaging in any medical conversation or decision making if the patient is unable to confirm it themselves. Sometimes the patient may be alert and conversant, but their decision-making capacity may seem questionable. If the patient is disagreeing with a choice that the clinician feels is the best option, it may seem irrational. So it is critical to talk to the patient and understand their point of view to understand their state of mind and make sure they are competent to make decisions.
Of course, this may not coincide with the legal determinants of competence, which are evaluated by the court in a standardised, formal manner. To avoid unpleasant run-ins with legal terminology, it is better to claim that the patient is competent enough for decision making and that they are fully capable of making choices. The determination of this is based on four domains:
- Whether the patient understands the clinical information that is presented
- The patient appreciates their situation, including consequences that follow the refusal of treatment.
- Patient can coherently display reason in deliberating about their choices
- The patient is able to communicate their choice in a clear, effective, assertive manner.
End-of-Life Care
End-of-life care aims to relieve any physical and psychological pain or symptoms while mitigating emotional and spiritual distress. There should be open support and empathy for the patient’s preferences and the level of care must be explained and adjusted according to that. The family members should be informed about what the dying patient may look, sound, and smell like after the initiation of comfort care. The palliative care team can be constructive in guiding this conversation. The organ donation team should discuss the possibility of donation at this time. This must specifically be done by the organ donation team and not the clinical team to avoid conflicts of interest. The funeral planning and financial arrangements can be discussed by a social worker.
Decision to withhold or withdraw
Decisions to withhold or withdraw life sustaining treatments can be tremendously challenging. These treatment can be emotional as well as ethical domains to all those involved. However, any patient who is capable of making decisions is allowed to request the termination of certain medications or ask that any medical intervention be stopped. Even when that decision would lead to their death in the foreseeable future.
Many clinicians feel that it is easier to not start (withhold) a treatment, such as mechanical ventilation than to stop (withdraw) it. There may be an emotional difference between withdrawing treatment that could prolong a patient’s life and withholding it entirely, but there is no clear ethical difference between the two. When a treatment no longer helps to achieve the patient’s goals for care or desired quality of life, it is ethically appropriate for physicians to withdraw it. This is a very important aspect of palliative care, where the caretaker often leaves out painful treatments or medications to keep the patient comfortable until they pass.
Withdrawing or withholding of life sustaining treatment is also considered euthanasia but passively. Rather than inducing death by introducing substances into the body, the treatment that could keep the body alive is removed. In some situations, it may be a conundrum as to whether the act of withholding or withdrawing treatment can be considered passive euthanasia or a part of palliative care. Since palliative care involves keeping a patient as comfortable as possible until the end of their life. A palliative care doctor might advise someone who is approaching death to stop taking certain medications. If they cause unpleasant side effects; or they may allow someone to take a much higher dose of a medication to treat severe pain. This is standard in palliative care and is generally not considered euthanasia or assisted suicide.
Conclusion
Understanding the patient, and curating an end-of-life plan for them involves a lot of emotional turmoil for all those in interaction with the process – the patient, family and even the clinicians. It is a time of preparing to let go of the patient. To understand the option that would keep them comfortable until they pass away. The necessity and competence of the patient or surrogate in making this decision must also be evaluated carefully. To avoid letting go of someone who could have, or would have wanted to live. Termination of life sustaining treatment, hence, is a sensitive issue that requires large amounts of patience, empathy and understanding.
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