Life-prolonging Treatment Research Articles

Withholding or withdrawing life-prolonging medical treatment

Withholding or withdrawing life-prolonging medical treatment

Withholding or Withdrawing Treatment-Reply

In Reply.— The Council on Ethical and Judicial Affairs (formerly the Judicial Council) provides opinions on various ethical issues in an effort to provide guidance to the medical profession and to the public. Reflecting its long-standing concern with providing guidance on the ethical issues surrounding the care of the dying patient, the Council recently issued the following opinion, which clarifies the Council's previously published opinion on terminal illness. Withholding or Withdrawing Life-Prolonging Medical Treatment The social commitment of the physician is to sustain life and relieve suffering. Where the performance of one duty conflicts with the other, the choice of the patient, or his family or legal representative if the patient is incompetent to act in his own behalf, should prevail. In the absence of the patient's choice or an authorized proxy, the physician must act in the best interest of the patient. For humane reasons, with informed consent, a

Withholding or Withdrawing Treatment

To the Editor.— The opinion of the American Medical Association (AMA) Council of Judicial and Ethical Affairs, Withholding or Withdrawing Life-Prolonging Medical Treatment, makes clear that artificially supplied nutrition and hydration are medical treatments, to be considered in the same light as other technological procedures that may, in some circumstances, only prolong dying. As with all other treatment, it is primarily the patient's wishes that determine whether tubal sustenance should be administered. The statement also clarifies a point that is frequently obscured: patients' rights are the same whether the patients' deaths are imminent or whether the dying process may be prolonged for months or years. Recently, three courts, in Florida, California, and New Jersey, handed down rulings consistent with the new AMA opinion: In Florida, the husband of 75-year-old Helen Corbett went to court to stop the artificial feeding that was maintaining his wife. The trial court ruled that it

Predicting the Outcome From Hypoxic-Ischemic Coma: Ethical Implications

To the Editor.— Dr Black's editorial 1 on predicting the outcome from hypoxic-ischemic coma correctly notes that predictors of bleak prognosis pose important ethical implications and that some of the key ethical assumptions may remain implicit and unexamined if one moves too quickly from prognostic judgments to public policy decisions. I question, however, his suggestion that a consequentialist analysis lies specifically at the root of any decision that one should withhold life-prolonging treatment from an irreversibly comatose patient. Consequentialist or utilitarian ethics are frequently contrasted to a deontological (rights- or duty-oriented) ethical approach. A fundamental deontological question therefore becomes what is required before one could be said to be the subject of rights and duties (since it is obvious that we should respect the rights of other normal human beings but that we should not worry about respecting the rights of trees and rocks). While opinions differ, one useful line of

Verantwortbare Risiken bei der Wahl der palliativen Chemotherapie

The risk of tumor chemotherapy is weighed against its therapeutical potential. If there is a chance of a curative or life-prolonging treatment, the choice of a rather aggressive form of chemotherapy is justified. In the majority of patients with metastatic malignant diseases, however, life-prolongation is not achievable and the choice of a chemotherapy with life-threatening side-effects contra-indicated. Potential benefits and risk of chemotherapy are further exemplified in breast cancer.

Death, Dying, and the Brain

These cases have been cited and these issues presented to make the point that principles are often out of phase with perceptions. The argument is not that principles should cede to perceptions. This would imply resignation to the unlikelihood of moral development. Neither do we claim that perceptions should simply and generally capitulate to principles. This could mean an intolerable dictatorship of one philosophy over experience. Clinical ethics is the challenge to integrate principles and perceptions continuously and critically in resolving value conflicts about the best care of individual patients.

Ethical Dilemmas for House Staff Physicians

Winkenwerder describes a disagreement about proper management of a critically ill patient that arose during his tenure as a house staff physician. Despite the attending physician's consideration of the family's wishes and the best interests of the patient, the resident was uneasy with the decision to continue life-prolonging treatment and the role he was to play in implementing such procedures. The author argues that ethical decisions within the group of physicians caring for a patient, especially one who is terminally ill, are not always resolved to everyone's satisfaction. What then are the rights and duties of residents to refuse further participation in care? Winkenwerder suggests dealing with conflicts through recognizing value differences, increasing formal ethics teaching, using consultants, and maximizing communication among members of patient care teams.

Case Studies: Who Speaks for the Patient with the Locked-In Syndrome?

A case is presented involving a nursing home patient who suffered a stroke that left him unable to speak or move, and thus unable to communicate his wishes except through eye movement. Steffen ponders several questions related to whether this patient should be given life-prolonging treatment, including whether he is competent to give or withhold consent, how a guardian could justify a third-party consent or refusal, and whether the attending physician could write a "do not resuscitate" order without the approval of the patient's guardian. He concludes intuitively that life-sustaining therapy should not be given in view of the patient's quality of life and the burden of his illness. Franklin disagrees, contending that it is unfair to withhold life-sustaining therapy because a patient cannot communicate and that there is an increasing number of cases on record of patients with locked-in syndrome who have recovered or have learned to communicate through Morse code or computers.

Ethics, Law, and Nutritional Support-Reply

—We thank Mr Landsman for his comments on the family's power to authorize nontreatment of their incompetent adult relatives. The Virginia statute does permit specified family members to authorize termination of life-prolonging treatment of incompetent adult relatives whose deaths are imminent. We would also like to note that the Texas legislature recently enacted a similar provision, which became effective Sept 1, 1985. The Maryland statute, however, allows relatives to give substituted consent for furnishing medical treatment to incompetent adult patients. This law fails to confer on family members explicit authority to refuse life-sustaining treatment on behalf of an incompetent adult relative. Although none of the court decisions Mr Landsman cites required judicial approval of nontreatment decisions, Conroy and Colyer required that decisions to terminate life-sustaining treatment be made by the incompetent patient's legal guardian. The Storar case failed to address the question of whether a legal guardian must authorize nontreatment.

Albendazole in hydatid disease.

<h3>ABSTRACT</h3> Despite advancement in treatment, prostate cancer (PCa) remains the second leading cause of death among men. Neuroendocrine prostate cancer (NEPC) represents one of the most lethal forms of PCa and lacks life-prolonging treatment. Here we identified histone lysine demethylase KDM4A as a drive in NEPC progression and an effective therapeutic target. We found that KDM4A mRNA and protein are overexpressed in human and mouse NEPC compared to adenocarcinoma. Also, we showed that knockdown or knockout of KDM4A in NEPC cell lines suppressed cancer cell growth <i>in vitro</i> and <i>in vivo</i>. Importantly, inactivation of <i>Kdm4a</i> in a genetically engineered mouse model of prostate cancer led to reduced tumor burden, reduced incidence of NEPC, and prolonged overall survival. Mechanistically, we found that <i>KDM4A</i> KD led to suppression of MYC signaling through direct transcriptional regulation of <i>MYC</i>. Importantly, MYC signaling is hyper-activated in human and mouse NEPC. Furthermore, a potent pan-KDM4 inhibitor QC6352 significantly reduced NEPC cell growth <i>in vitro</i> and <i>in vivo</i>. Taken together, we demonstrated that KDM4A drives NEPC progression through regulation of MYC and targeting KDM4A can potentially be an effective therapeutic strategy for NEPC.

Withholding of Life-Sustaining Treatment From the Terminally III, Incompetent Patient: Who Decides?

Part I of this article traced the early development of the law regarding decisions to discontinue potentially life-prolonging treatment of terminally ill patients (1982; 248:2250). In the seminal case of<i>In re Quinlan</i>, 355 A2d 647 (NJ 1976), the New Jersey Supreme Court held that a patient's constitutional right of privacy includes the right to refuse treatment where such treatment can only perpetuate a comatose, vegetative existence. Furthermore, this privacy right may be exercised on the incompetent patient's behalf by the guardian, family, and attending physicians, with the approval of the ethics committee of the hospital involved. Subsequent decisions in other jurisdictions have endorsed<i>Quinlan's</i>constitutional rights analysis and have adopted, in principle, the concept of "substituted judgment." Many courts have rejected<i>Quinlan's</i>formula for private decision making, however, opting instead to delineate guidelines for determining when judicial approval is required to implement nontreatment decisions.<i>Superintendent of Belchertown State School</i>

Extraordinary means and the intentional termination of life

Physicians and their professional organizations often distinguish between ordinary and extra-ordinary means of treatment. The moral relevance of this distinction, which has recently been defended by the philosopher Bonnie Steinbock (The Intentional Termination of Life. Ethics Sci. Med. 6, 59, 1979.). is challenged. It is argued that neither this nor the “overlapping distinction” between intention and foresight is morally significant. If deliberate cessation of ordinary treatment, resulting in the foreseen death of the patient, is the intentional termination of life—so is the deliberate cessation of extraordinary treatment. Two interrelated arguments are advanced in support of the claim that the distinction between ordinary and extraordinary means of life-support has no moral significance. The first is based on Steinbeck's own criterion for the intentional termination of life (“if one acts intentionally, foreseeing that a particular result will occur, one can be said to have brought about the result intentionally”), the second suggests that the distinction between ordinary and extraordinary means is a distinction not between different means but between lives judged worthy of prolongation and those not: it is a quality-of-life criterion. This explains why the concept of extraordinary means is “flexible”, why “what might be considered ‘extraordinary’ in one situation might be ordinary in another”. But if we do not admit that quality-of-life considerations rather than “means” are at issue, then we cannot give an adequate answer as to why it may. for example, be morally permissible to switch off the respirator when it sustains an irreversibly comatose patient but not when it sustains a patient with a respiratory disease. It is argued that when the physician intentionally flicks the switch to turn off the respirator, foreseeing the death of the patient, then he has brought about the death intentionally and it does not matter whether we call the respirator in the first case an “extraordinary” and in the second case an “ordinary” means. The deliberate cessation of life-prolonging treatment is the intentional termination of life—either passive euthanasis or. if the patient against his doctor's advice, refuses further treatment. passive suicide.

Medical Paternalism or Legal Imperialism: Not the Only Alternatives for HandlingSaikewicz-type Cases

In 1977, the Supreme Judicial Court of Massachusetts held in the Saikewicz case that the probate court is the proper tribunal for making decisions whether to give or withhold "life-prolonging treatment" for terminally ill incompetent patients. This ruling provoked debate in the medical and legal communities. Dr. Arnold Relman, Editor of The New England Journal of Medicine, argues that Saikewicz encroaches on existing sound medical practice and requires decision-making machinery that is impractical and inhumane. Relman contends that treatment decision for terminally ill incompetents in Saikewicz-type cases should be made by the physician in consultation with the patient's family. Law professor Charles Baron, in contrast, defends Saikewicz's judicialization approach, arguing that such decision must bemade in an adversary framework that approximates the ideal of the rule of law. In the present Article, Professor Buchanan argues that Relman's criticism of Saikewicz rests on a defective, medical paternalist view of the physician-patient relationship, and that Baron's support of Saikewicz is based on an unjustifiable, legal imperalist view of decision making for incompetents. In Buchanan's view, Relman's approach fails to distinguish appropriately between the making of medical judgments and the making of moral judgments and wrongly assumes that the patient's family typically cannot understand the elements of the decision, while Baron's approach unjustifiably extends the sphere of the legal process by ignoring the special moral relationship that usually exists between the family and its incompetent member. Buchanan proposes an alternative decision-making approach that he believes incorporates the merits, while remedying the defects, of both Baron's and Relman's approaches. The alternative is based on three propositions. (1) The proper presumption in Saikewicz-type cases is that the family of an incompetent is to make decisions concerning treatment. (2) This presumption of the family's dominant role in decision making is defeasible: protection of the patient's rights requires that decisions be made within a framework that allows vigorous discussion and accoutability through impartial review and that provides for legal intervention when necessary. (3) The institutional framework for implementing the features listed in the preceding proposition will rely heavily upon an ethics committee that is neither an all-medical prognosis committee nor an administrative agency of the hospital. Besides evaluating and responding to the Relman and Baron approaches, Buchanan examines the contribution to the Saikewicz debate made by law-and-medicine professor George Annas. In essence, Buchanan rejects Annas's argument that, taken together, the Saikewicz opinion and the Quinlan opinion of the Supreme Court of New Jersey delineate a proper division of medical and legal decision-making responsibility concerning terminally ill incompetents. Buchanan concludes that, contrary to Annas's view, those two cases are not reconcilable.

The changing attitudes of physicians toward prolonging life.

This follow-up survey of physicians' attitudes and practices reveals a changing approach toward the care of terminal patients. It shows that: 1) communication with dying patients is becoming more open, 2) support for the omission of life-prolonging treatments is increasing, and 3) opposition to the use of death-hastening measures remains strong. It indicates that the physician's experience with terminal patients and the setting of his practice influence his attitude towards these patients and the approach to treatment.