Forgoing Life Support Research Articles

Killing by Organ Procurement: Brain-Based Death and Legal Fictions

The dead donor rule (DDR) governs procuring life-prolonging organs. They should be taken only from deceased donors. Miller and Truog have proposed abandoning the rule when patients have decided to forgo life-sustaining treatment and have consented to procurement. Organs could then be procured from living patients, thus killing them by organ procurement. This proposal warrants careful examination. They convincingly argue that current brain or circulatory death pronouncement misidentifies the biologically dead. After arguing convincingly that physicians already cause death by withdrawing treatment, they claim no bright-line differences preclude organ removal from the living. The argument fails for those who accept the double effect doctrine or other grounds for distinguishing forgoing life support from active, intentional killing. If the goal is determining irreversible loss of somatic function, they correctly label current death pronouncement a "legal fiction." Recognizing a second, public policy meaning of the term death provides grounds for maintaining the DDR without jeopardizing procurement.

Ethical aspects of care in the newborn surgical patient

This article places focus on three main subjects that are all related to the ethical aspects of care of newborns undergoing major surgical interventions. The first concerns the communication between the surgeon, as a representative of the treatment team, and the parents. The second is the way to handle new developments in neonatal surgery. The third issue covers several aspects of the ethical decision-making process with regard to forgoing life support in surgical neonates. These issues will be discussed on the basis of two clinical case reports.

Euthanasia: a misunderstood term

Although the word 'euthanasia', a compound word of eu- (good, well) and thanatos (death) is widely known, it is greatly misunderstood. With regard to end-of-life medicine, several phrases, including death with dignity, passive euthanasia, and natural death also need to be clarified. A review of their meanings and connotations is provided along with a brief history of the discussion in Korea on forgoing life support. Korea has no law regarding the cessation of artificial ventilation, but several judgments of law courts provide us with a general principle that cessation could be applied if the patient is in an irreversible or dying condition medically, and has presented his or her intention with something like an advance directives, or is reasonably presumed to have such a will.

Forgoing life support: how the decision is made in European pediatric intensive care units

To determine how decisions to forgo life support are made in European pediatric intensive care units (PICUs). A multicenter, prospective study, the Eurydice II study, among 45 PICUs: 20 in France, 21 in Northern/Western (N/W) European countries, and 4 in Eastern/Central (E/C) Europe. Data were collected between November 2009 and April 2010 through a questionnaire. The decision to forgo life-sustaining treatment was made in 166 (40.6%) out of 409 deceased children (median 42.9%, France 38.2%, N/W European countries 60.0%, E/C European countries 0%; P < 0.001). In the E/C group, more patients died after cardiopulmonary resuscitation (CPR) failure than after forgoing life support (P < 0.001). In all PICUs, caregivers discussed the decision during a formal meeting, after which the medical staff made the final decision. The decision was often documented in the medical record (median 100%). The majority of the parents were informed of the final decision and were at the bedside during their child's death (median 100%). Decision to forgo life-sustaining treatment occurred in 40.6% of children, compared with 33% in Eurydice I. A high percentage of parents from France were now informed about the meeting and its conclusion as compared with Eurydice I (median 100%). The results of this study and comparison with the Eurydice I study (2002) show a trend towards standardization of end-of-life practices across N/W European countries and France in the past decade.

The Evolution of Death and Dying Controversies

When Institute of Society, Ethics and Life Sciences (now The Hastings Center) began its death and dying work in 1970, first task was to disentangle definition of death from decisions to forgo life support. We were still in an era when it was often assumed that if one was alive, then health professionals should launch a full-court press to preserve life. The members of Institute's Task Force on Death and Dying went to work teasing these two questions apart. The first major public product contributed to making this basic distinction. A symposium at American Association for Advancement of Science (AAAS) in December 1970 included papers directed at clarifying definition of death. Authors included task force members Robert Morison and Henry Beecher, who was also chairman of Ad Hoc Committee of Harvard Medical School that established definition of brain death. In a debate between them and their commentators (Leon Kass and me), issues were whether death was a process or a momentary event and whether any support remained for a cardiac definition of death. The process/event debate was published in Science. (1) The clear result was recognition that while dying is a process (one that is extremely hard to differentiate from chronic illness), death itself is a momentary event, a bright line marking boundary between being a member of human community of living and those formerly living. Early on, we recognized crucial public, social, psychological, and legal significance of a categorical distinction between life and death. This distinction must be clear to decide whether spouses count as widows or assaults as homicides, for example, or whether life-insurance policies should pay off and assassinated presidents be succeeded by their vice presidents. If one accepts what is called donor being dead is a necessary condition for legitimately procuring life-prolonging organs. We also recognized that cluster of issues traditionally associated with death might be disaggregated so that some of conditions could be separated from pronouncement of death. Under special circumstances, for example, life insurance might pay off while one was still alive, such as in programs in which terminally ill are allowed to collect their insurance (at a discounted rate) in order to pay medical and other bills. One of conditions that The Hastings Center disaggregated early on was forgoing life support. With forty years of hindsight, it is remarkable how simple definition-of-death debate seemed back then. We recognized only two options at that time: one died either when circulatory function ceased irreversibly or when all brain functions stopped irreversibly, and most of us thought brain function option was more rational, modern view. Moreover, no one questioned dead donor rule, although many realized that a lot more was at stake in debate over definition of death than just procurement of organs. The early work of task force (eventually called research group) led to a consensus in favor of a whole-brain-based definition of death. The position was endorsed by entire group (although some of more thoughtful, provocative members pressed hard about potential dangers of abandoning cardiac definition). (2) This effort led two group members to propose a carefully crafted whole-brain definition that eventually shaped work of President's Commission for Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. (3) Toward Greater Complexity In retrospect, this simple two-option choice was already in jeopardy by time of AAAS meeting. Henry Beecher's unpublished presentation contained a hidden challenge. (4) In defending critical role of brain, he argued that the individual's personality, his conscious life, his uniqueness, his capacity for remembering, judging, reasoning, acting, enjoying, worrying, and so on, reside in brain, and . …

Intercontinental differences in end-of-life attitudes in the pediatric intensive care unit: Results of a worldwide survey*

To examine intercontinental differences in end-of-life practices in pediatric intensive care units. An international survey. The on-line questionnaire consisted of two case scenarios with five questions each. The scenarios described the management of children in pediatric intensive care units and the questions dealt with the decision-making process and the modalities of forgoing life support. The participants at the 5th World Congress on Pediatric Critical Care Medicine organized by the World Federation of Pediatric Intensive and Critical Care Societies (June 2007, Geneva, Switzerland) were invited to participate. None. Six hundred sixty seven complete questionnaires were received from 71 countries, which were grouped into six continents: Europe (52.7%), North America (17.9%) and South America (9.5%), Asia (7.6%), Australia (6%), and Middle East (4.3%). In both scenarios, physicians played the major role in decision making in all of the continents. However, parents from North America, Australia, the Middle East, and Asia seem to be more involved in the decision-making process, compared with those from Europe and South America. In cases of septic shock, caregivers from Europe and South America are more prone to forego life support despite parents' wishes. In North America and Australia, parents' presence during cardiopulmonary resuscitation is usually accepted (89.7% and 92.3%, respectively), whereas their presence is less accepted in Asia (54%) and Europe (54.8%), or much less accepted in South America (25.8%) and the Middle East (7.1%). In both scenarios, the option to withhold rather than withdraw life supports was more commonly chosen among all continents, except South America, where the withdrawal of life support was more often proposed (51.6% vs. 45.2%). This study confirms that important intercontinental differences exist toward end-of-life issues in pediatric intensive care. Although the legal and ethical situation is rapidly evolving, a certain degree of paternalism seems to persist among European and South-American caregivers. This study suggests that ethical principles depend on the cultural roots of countries or continents, emphasizing the need to foster dialogue on end-of-life issues around the world to learn from each other and improve end-of-life care in pediatric intensive care units.

Autonomia: viver a própria vida e morrer a própria morte

The present study describes the changes that have occurred in most Western countries, Brazil included, since medicine has shifted progressively from a paternalistic model to one that promotes patients autonomy and self-determination. Respect for patient autonomy and self-determination is the primary basis for withholding and withdrawing life support. An adult patient who has decision-making capacity and is appropriately informed has the right to forgo all forms of medical therapy, including life support measures. The right to refuse treatment applies equally to withholding therapy that might be offered, such as cardiopulmonary resuscitation, and to withdrawing therapy that is already underway, such as artificial hydration, nutrition, and ventilation. This right is based on the ethical principle of autonomy or self-determination. Helping an informed and capable patient to forgo life support under these circumstances is regarded as distinct from participating in requested homicide, assisted suicide, or passive/active euthanasia. The patient has the right to choose, including where the deathbed will be placed, and to be left alone with family at that time.

What influences parents??? decisions to limit or withdraw life support?*

Decisions to forgo life support from critically ill children are commonly faced by parents and physicians. Previous research regarding parents' perspectives on the decision-making process has been limited by retrospective methods and the use of closed-ended questionnaires. We prospectively identified and described parents' self-reported influences on decisions to forgo life support from their children. Deeper understanding of parents' views will allow physicians to focus end-of-life discussions on factors important to parents and help resolve conflicts. Prospective, qualitative pilot study. Pediatric intensive care unit of a university-affiliated children's hospital. A total of 14 parents of ten children whose pediatric intensive care unit physician had made a recommendation to limit or withdraw life support. : In-depth, semistructured interviews were conducted with parents during their decision-making process. Factors influencing the parents in this study in their decision to forgo life support included their previous experience with death and end-of-life decision making for others, their personal observations of their child's suffering, their perceptions of their child's will to survive, their need to protect and advocate for their child, and the family's financial resources and concerns regarding life-long care. Parents in this study expressed the desire to do what is best for their child but struggled with feelings of selfishness, guilt, and the need to avoid agony and sorrow. Physician recommendations, review of options, and joint formulation of a plan helped parents gain a sense of control over their situation. Parents of eight children agreed to forgo life support and parents of two did not. Prospective interviews with open-ended questions identified factors influencing parents' decision making not previously described in the critical care literature such as parents' past experiences with end-of-life decisions and their anticipated emotional adjustments and future resources. Inclusion of these factors into discussions is important to parents and may facilitate decisions regarding the limitation or withdrawal of life support.

The Catholic Tradition on Forgoing Life Support

The Catholic Tradition on Forgoing Life Support

Limiting life-prolonging interventions and providing palliative care towards the end-of-life in Indian intensive care units

Purpose: This position statement aims to minimize inappropriate treatment and optimize palliative care for terminally ill patients in Indian intensive care units by standardizing the process of forgoing life support. It also defines the ethical standards for the physician–patient relationship in the context of critical care practice in India. Evidence: Evidence was gathered through a review of recently published medical literature on the subject, as well as by evaluating the relevant statutes of Indian Law. Available empirical data from critical care practice in India were sparse. Newspaper articles reflecting lay opinion on related issues were also reviewed. The terms for search were: end-of-life care; withdrawal and withholding; intensive care; terminal care; medical futility; ethical issues; palliative care. Method: Proposals from the Chair were debated and recommendations were formulated through a consensus process. The process took into account the guiding ethical principles and clinical practices elsewhere in the world, and incorporated the socio-cultural and legal perspectives unique to this country.

Another matter of life and death: what every anesthesiologist should know about the ethical, legal, and policy implications of the non-heart-beating cadaver organ donor.

Summary It remains to be seen whether the use of NHBCDs willsignificantly increase the number of organs available fortransplantation. Organ retrieval from such donors maybe ethical, provided that conflicts of interest amonghealthcare providers are defined and prevented, the ex-ploitation of vulnerable persons is avoided, the with-drawal of care is in accordance with accepted and ap-propriate medical standards, the inadvertent harvestingof vital organs from living patients does not occur, andthe humane treatment of dying patients and their fami-lies is safeguarded. Further, the process must not beimplemented in ways that cause distrust among dyingpatients that their medical and social needs will be putsecondary to those of patients needing transplantableorgans. It is arguable whether any existing protocolcompletely addresses all of these issues.Any anesthesiologist involved with either policies orcare of patients who will become NHBCDs should beeducated about the legal, ethical, and medical issuesinvolved and should not undertake such duties withoutadequate knowledge and training. Even when with-drawal of care is anticipated in an operating room set-ting, only physicians with appropriate knowledge, train-ing, and experience in the withdrawal of life support andcomfort care of the dying patient should be involvedwith the NHBCD. Such specialty expertise is not withinthe customary training and practice of most anesthesiol-ogists. The physician withdrawing life support should besomeone who has been involved with the patient andfamily throughout the decision-making process, so thatdeath does not become, as Renee Fox described it, a“desolate, profanely ‘high-tech’ death that the patientdies, beneath operating room lights, amid masked,gowned, and gloved strangers.”

Forgoing life-sustaining treatments: how the decision is made in French pediatric intensive care units.

The decision to forgo life support is frequently made in pediatric intensive care units (PICUs). A group of experts is currently preparing recommendations for guidelines concerning this decision-making process in France. We have performed a prospective study to help the experts. This study documents how children die in French PICUs and how the decision to limit life support is made. A multicenter, prospective, cross-sectional study. Thirty-three multidisciplinary PICUs in university hospitals. All consecutive deaths were recorded over a 4-month period. Children who died after a medical decision to forgo life-sustaining treatment were included in group 1 and children who died from other causes were included in group 1. A total of 264 consecutive children died, 40.1% from group 1 and 59.8% from group 2. Patients of both groups were primarily admitted for acute respiratory failure (group 1, 50.8%; group 2, 52.6%). Neurologic emergencies were more frequent in patients in group 1, whereas patients with cardiovascular failures were more frequent in group 2. When there was a question of whether to pursue life-sustaining treatment, the parents' opinions were recorded in 72.1% of cases. A specific meeting was called to make this decision in 80.1% of cases. This meeting involved the medical staff in all cases. Parents were aware of the meeting in 10.7% of cases. The conclusion of the meeting was reported to the parents in 18.7% of cases and documented in the patient's medical record in 16% of cases. Experts who were not members of the PICU staff were invited to give their opinion in 62.2% of cases. The decision to forgo life-sustaining treatment is frequently made for children dying in French PICUs. Guidelines must be available to help the medical staff reach this decision. Knowledge of the decision-making process in French PICUs provides the experts with information needed to elaborate such recommendations.

Not if, but how: one way to talk with patients about forgoing life support

May the common clinical conversation be used to explore whether or not seriously ill patients want to talk about possible limitations of life support? In order to answer this question,...

Forgoing life support in western European intensive care units: the results of an ethical questionnaire.

To determine current views of European intensive care physicians regarding end-of-life decisions. A questionnaire was sent to all physician members of the European Society of Intensive Care Medicine. All questionnaires were anonymous. A total of 504 completed questionnaires from 16 western European countries were analyzed. Eighty-seven percent of the respondents were male. Forty-six percent of respondents said that intensive care unit admissions were generally or commonly affected by bed shortages, particularly in the south. Nevertheless, 73% of units frequently admit patients with no hope of survival, although only 33% of respondents felt that such patients should be admitted. Eighty percent of respondents felt that written do-not-resuscitate orders should be applied, but only 58% did so, with a wide variation according to country (from 8% in Italy to 91% in The Netherlands). Ninety-three percent of physicians sometimes withhold treatment from patients with no hope of a meaningful life, but withdrawal of treatment is less common. Forty percent of respondents said that they would deliberately administer large doses of drugs to such patients until death ensued. Forty-nine percent of respondents involved staff, patients, and family in end-of-life decisions. Forty-five percent of respondents felt that an ethics consultation was useful in such situations. Physicians in the countries of southern Europe were less likely than those in the north to apply do-not-resuscitate orders, withhold treatment, and discuss such issues with the patients. However, they were more likely to value the opinion of an ethics consultant. Intensive care unit admissions are frequently limited by the availability of beds across Europe, particularly in the south and in the United Kingdom, yet 73% of intensivists still admit patients with no hope of survival. When treating patients with no hope of survival, 40% of intensivists will deliberately administer large doses of drugs until death ensues. There are interesting differences between what a physician actually does and what he or she believes should be done with regard to various ethical questions. Important differences in attitudes also exist between European countries.

Ethnicity and attitudes towards life sustaining technology

The ethical and legal implications of decisions to withhold and withdraw life support have been widely debated. Making end-of-life decisions is never easy, and when the cultural background of doctor and patient differ, communication about these issues may become even more difficult. In this study, we examined the attitudes of people aged 65 and older from different ethnic groups toward forgoing life support. To this end, we conducted a survey of 200 respondents from each of four ethnic groups: European-American, African-American, Korean-American and Mexican-American (800 total), followed by in-depth ethnographic interviews with 80 respondents. European-Americans were the least likely to both accept and want life-support ( p<0.001). Mexican-Americans were generally more positive about the use of life-support and were more likely to personally want such treatments ( p<0.001). Ethnographic interviews revealed that this was due to their belief that life-support would not be suggested if a case was truly hopeless. Compared to European-Americans, Korean-Americans were very positive regarding life-support (RR=6.7, p<0.0001); however, they did not want such technology personally (RR=1.2, p=0.45). Ethnographic interviews revealed that the decision of life support would be made by their family. Compared to European-Americans, African-Americans felt that it was generally acceptable to withhold or withdraw life-support (RR=1.6, p=0.06), but were the most likely to want to be kept alive on life-support (RR=2.1, p=0.002). Ethnographic interviews documented a deep distrust towards the health care system and a fear that health care was based on one's ability to pay. We concluded that (a) ethnicity is strongly related to attitudes toward and personal wishes for the use of life support in the event of coma or terminal illness, and (b) this relationship was complex and in some cases, contradictory.

Letting go: Family willingness to forgo life support

To describe the process of family decision making about life support in the critical care setting. Descriptive, exploratory. A northeastern United States university-affiliated medical intensive care unit. Thirty family members of 16 critically ill patients. Letting go or becoming willing to forgo life support involved three interrelated and complex processes: (1) family members sought out, obtained, and tried to understand information about the critical illness; (2) they reviewed the life story of the patient, seeking meaning in the patient's life and the critical illness; and (3) they struggled to maintain family roles and relationships. For most families, interpersonal and intrapsychic work during each process created a reframing of the issues related to the critical illness: (1) they came to believe that they had done all that could be done and were able then to relinquish the goal of recovery for acceptance of a peaceful death; (2) they reviewed the patients's life, finding some meaning and a sense that, given the situation, the patient would not want to continue on life support, and then they moved toward closure; and (3) they were able to bring about (at least within a small group of the closest family members) a sense of doing the "right thing", and they were able to develop some sense that forgoing life support for the ill relative would not destroy important family relationships. For a few other families this movement toward resolution did not occur, and although family members attempted to deal with the issues of life support, their efforts were fraught with conflict and prolongation of the end-of-life period. Little is known about the actual experience of family members as they are involved in life-support decision making. Identification of the needs of family members to work through the decision-making experience cognitively, emotionally, and morally is essential to communicating effectively about the ill relative's condition and to providing understanding and support to families involved in life-support decision making in the critical care unit.

The High Risk Patient: Management of the Critically III

This nearly 1800-page text provides a novel approach to the intensive care unit (ICU) patient, whom the editors have attempted to place within the continuum of hospitalized patients. Major sections of the book are further divided into preICU, ICU, and post-ICU sections. In addition, The High Risk Patient is timely in its attempt to provide detailed information for prognostic and predictive efforts. Practical references to meta-analysis, APACHE (Acute Physiology and Chronic Health Evaluation) severity scoring, and biostatistics are found throughout. Additionally, interrelated issues of critical care, such as nutrition and respiratory failure, are cross-linked. This text is unique in several areas, one of which is a detailed discussion of the skin as a critical organ. In addition, the chapters on minimizing the risk of liability and Forgoing Life Support or Death Prolonging Therapy are both current and relevant and can serve as a nidus for discussion in many ICUs. Particularly

Decisions to limit or continue life-sustaining treatment by critical care physicians in the United States: conflicts between physicians' practices and patients' wishes.

We surveyed a national sample of 879 physicians practicing in adult intensive care units in the United States, in order to determine their practices with regard to limiting life-sustaining medical treatment, and particularly their decisions to continue or forgo life support without the consent or against the wishes of patients or surrogates. Virtually all of the respondents (96%) have withheld and withdrawn life-sustaining medical treatment on the expectation of a patient's death, and most do so frequently in the course of a year. Many physicians continue life-sustaining treatment despite patient or surrogate wishes that it be discontinued (34%), and many unilaterally withhold (83%) or withdraw (82%) life-sustaining treatment that they judge to be futile. Some of these decisions are made without the knowledge or consent of patients or their surrogates, and some are made over their objections. We conclude that physicians do not reflexively accept requests by patients or surrogates to limit or continue life-sustaining treatment, but place these requests alongside a collection of other factors, including assessments of prognosis and perceptions of other ethical, legal, and policy guidelines. While debate continues about the ethical and legal foundations of medical futility, our results suggest that most critical care physicians are incorporating some concept of medical futility into decision making at the bedside.