EthicsThe Durban World Congress Ethics Round Table Conference Report: I. Differences between withholding and withdrawing life-sustaining treatments☆
Introduction
Forty years ago, patients typically died in intensive care units (ICUs) after failed cardiopulmonary resuscitation (CPR). Over the ensuing years, foregoing of life-sustaining treatments has become a more common way for ICU patients to die. Studies around the world have demonstrated that forgoing of life-sustaining treatments occurs in 1.5% to 22% of patients admitted to ICUs [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11] and that forgoing of life-sustaining treatments occurs in 23% to 93% of patients who die [2], [4], [6], [10], [11], [12], [13], [14], [15], [16]. In these studies, death was preceded in 8% to 70% of patients by withholding of life-sustaining treatments [4], [6], [9], [13], [15], [16], [17], [18], [19] and in 3% to 69% of patients by withdrawing of life-sustaining therapies [4], [6], [8], [9], [13], [15], [16], [17], [18], [19]. Among individual ICUs within countries and regions, withholding life-sustaining treatments (WHLST) may range from 0% to 67% [2], whereas withdrawal of life-sustaining therapies may range from 0% to 96% [2], [6], [8]. Clearly, there is a significant variation in practice among the different ICUs not only in different countries but also in different parts of a country [2], [6], [8]. In addition, there is evidence that limiting life-sustaining treatments has become more frequent in recent years [13].
The experience in neonates and children is extensive and reveals differences in approaches in neonatal and pediatric critical care units as well as regional variations within and between countries. For instance, in North America, Northern Europe, and Australia, it is rare in neonatal intensive care for infants to die while receiving CPR and uncommon in pediatric ICUs (PICUs). Generally, 18% to 65% of pediatric ICUs practice withdrawing or withholding of life-sustaining therapy or institute do-not-resuscitate orders with higher rates (30%-65%) in North America and Northern Europe, whereas in Eastern Central Europe, decisions to forego life-sustaining therapy are almost nonexistent [20], [21]. There are also regional differences worldwide on how decisions regarding withholding or withdrawing life-sustaining decisions are made and to what extent families are involved. In most cases, decisions are made after discussion among the medical team, and parents may be informed of the decision and may or may not be asked for their permission [20], [21], [22], [23], [24], [25]. In addition, difficulty in reaching consensus is usually resolved over time [26], [27], and the approach to the use of sedatives and neuromuscular blockers is subject to individual preferences [23], [28], [29]. There are also differences in approach depending on race and resources in that limiting therapy is less likely if the patient is black or in units with no trainees [30].
There are a number of reasons for these considerable differences in practices in the various ICUs. These may include legal and regulatory issues and legal precedents within the country; the religious and/or cultural beliefs and practices of both the health care professionals and the patients and their families; the speciality of the attending physician; and the patient profile, which may include the medical condition itself as well as race/ethnicity and socioeconomic factors [31], [32], [33], [34], [35], [36], [37], [38], [39].
Recognizing the different worldwide contexts and practices, during the World Federation of Societies of Intensive and Critical Care Medicine Congress in August and September 2013 in Durban, South Africa, an ethics round table was convened as a component of the scientific program. Round table participants were polled as to whether they believed there was a moral difference between withholding and withdrawing mechanical ventilation. This article reports their opinions and attempts to delineate the issues and discuss the reasons why withdrawing therapies is equivalent or better than withholding them or whether withholding therapies is superior to withdrawing. In addition, official statements relating to withholding or withdrawing life-sustaining treatments from intensive care societies, professional bodies, and government statements were sourced, documented, and compared.
To highlight the differences between withholding or withdrawing mechanical ventilation a clinical example where those who support equivalence of withholding and withdrawing therapy or reject equivalence would reach different answers is provided. An 86-year-old man with diffuse non-Hodgkin lymphoma relapsing after a third course of chemotherapy with a cerebral Aspergillus infection undergoes a cardiac arrest in the emergency department (ED). Not being aware of the patient's advance directive, the ED physician intubates, ventilates, and transfers the patient to the ICU. When the intensivist on call (who supports the equivalence of withholding and withdrawing therapy) discovers that the patient has an advance directive stating that he would not want to be intubated or ventilated or to undergo CPR, she extubates the patient and continues other medical and palliative care. She reasons that, if the ED physician would have been aware of the advance directive, he never would have intubated the patient in the first place and the patient's wishes should now be respected by withdrawing the endotracheal tube and ventilation. Another ICU physician (who does not support the equivalence of withholding and withdrawing therapy) states that the endotracheal tube and ventilation should not be withdrawn, although the patient would not have been intubated and ventilated if there would have been knowledge of the advance directive and, currently, the patient is receiving treatment he does not desire. He reasons that despite the fact that the intubation and ventilation could have been withheld, once started it cannot be withdrawn.
Section snippets
Methods
Speakers from the invited faculty list of the World Federation of Societies of Intensive and Critical Care Medicine Congress with an interest in ethics were approached to participate in the ethics round table. Round table participants were asked to identify their 3 most pressing specific worldwide ethical issues that the group should address. Most responded that they were interested in end-of-life issues including withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining
Results
Respondents' answers to the statement “There is no moral difference between withholding and withdrawing a mechanical ventilator” are outlined in Table 1. Sixteen respondents stated that there was no moral difference between withholding or withdrawing a mechanical ventilator, 2 were neutral, and 4 stated that there was a moral difference. The round table participant country laws or intensive care society statements regarding differences between WHLST and WDLST are shown in Table 2.
Organizations and government statements on the differences between WHLST and WDLST
It is increasingly recognized that, in certain circumstances, limitations of life-sustaining therapies in the critically ill may be both medically and ethically appropriate, and to achieve this limitation of therapy, treatment may either be withheld or withdrawn. Withholding life-sustaining treatments is defined as a decision not to start or increase a life-sustaining intervention, whereas withdrawing life-saving therapies is defined as a decision to actively stop a life-sustaining intervention
Reasons why WDLST is equivalent to or better than WHLST
As noted above, most professional opinions are that withholding and withdrawing life-prolonging therapies are ethically equivalent. In fact, several of the major religions permit both the withholding and the withdrawing of nonbeneficial life-sustaining treatments in terminally ill patients. This includes Christians (Roman Catholics and Protestants), Muslims, and Buddhists [71]. Interestingly, the Greek Orthodox Church equates withholding with withdrawing therapy but prohibits both as it
Reasons why WHLST is not equivalent to WDLST
Although most organizations and ethicists believe that there is no moral difference between WHLST and WDLST, some clinicians and, specifically, a few in the round table do not share that view [75]. One of the suggested reasons is that withholding is passive and withdrawing is active. Although some experts [64] state that there is no moral difference between actions and omissions, the fact that patients die much more frequently and quicker after the withdrawal of therapy is associated with a
Limitations and strengths
The present study has strengths. A group of intensivists from around the world with divergent cultures, religions, and professional opinions and many with a specific interest in ethics researched; evaluated the literature, law and professional statements; voted; and discussed issues related to withholding and withdrawing life-sustaining therapies. The present study also has limitations. Although the small number of respondents represents a diverse group of intensivists from around the world,
Conclusion
Although most ethicists and professional organizations have stated that there is no moral or legal difference between WHLST and WDLST, some health care professionals still do not accept their equivalency in practice. Several authors have proposed that health care professionals be further educated so they can accept their equivalence [66] and others have made proposals for implementing equivalence [66]. Most intensive care clinicians in previous surveys and at the round table believe that there
References (0)
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Conflicts of interest: None for any of the authors have conflicts of interest except Christiane Hartog who receives funding from the German Federal Ministry of Education and Research for research on end-of-life care in the intensive care unit.