by Dominic Wilkinson
Today I gave a talk at the John Radcliffe Medical Grand Round on Advance Directives and treatment withdrawal decisions in intensive care – based on a case I was involved in last year.
A middle-aged patient presents with acute respiratory failure, and is intubated and transferred to the intensive care unit. After admission he improves, but it transpires that he has a progressive neurodegenerative disorder and has previously expressed a wish not to have intensive life support measures provided.
- Should he be taken off life support immediately?
- Should he be allowed to improve a little further before removing him from life support, with a plan not to reinstitute intensive care?
- Should he be treated medically as any other patient, including receiving a tracheostomy if necessary?
- Is there a difference between withholding treatment and withdrawing treatment? Why do ethicists and doctors have different views on this?
- What is the ethical and legal status of advance directives when it comes to withdrawing intensive care?
This talk is the first in a series of grand rounds and seminars on ethical issues in critical care over the next 6 months. I have added below today's presentation with links to some of the papers and stories mentioned in the talk.
See also this blog post – just added, expanding on the argument that Julian refers to in his comment below – about resource allocation and the difference between withdrawing and withholding treatment.
If anyone is interested in being on the mailing list for this seminar series please drop me a line.
Here is the
Critical Care ethics grand round presentation (pdf) (minus case details)
Links
New GMC guidance: Treatment and care towards the end of life
Advance Directives in intensive care: John Griffiths
Silveira, NEJM — Advance Directives and Outcomes of Surrogate Decision Making before Death
Gillick, Reversing the code status of advance directives NEJM 2010
Acts and omissions revisited — Hope 26 (4): 227 — Journal of Medical Ethics
News stories:
Who will make your end of life decision? CNN
Job threat to doctors who ignore living wills Mail online
Doctors can be struck off if they ignore the right to die, GMC to announce – Telegraph
For this doctor DNR means 'Do not resign' NPR
Half the population would make a 'living will' if it was easy, says new poll – Telegraph
Suicide woman allowed to die because doctors feared saving her would be assault – Telegraph
This is a nice talk. Dom made the novel point that limitation of resources is often used to not admit a critically ill patient to ICU but it virtually never used as a reason to withdraw ICU and allow a patient to die. I believe this is inconsistent and wrong.
Resource limitation and distributive justice considerations are the most important criteria for withholding and withdrawing life sustaining medical treatment inc ICU, after the person’s own wishes (advance directives). But there is virtually no literature on that. It is much easier to say that A’s life is more valuable/better prognosis/better quality of life/better life expectancy than B’s than it is to say that A’s life is not worth living, in itself. Comparative judgements are easier and more reliable than absolute judgements of whether life is worth living.
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