Withholding/Withdrawal Life Support:Killing vs Letting Die
A topic which I have posed on my currently not updated "Bioethics Discussion Pages" is one of whether patient or surrogate requested removal of life support or to withhold life supportive treatment represents forms of "killing" or is it really a process of "letting" the patient die from the underlying disease for which the life support was being or was to be used. A visitor to that web site wrote me the following response which I thought was so well written that I would put it up on this blog. What do you think are the distinctions? ..Maurice.
Your question important for all of us. My father-in-law chose death at his
own hand when confronted with a diagnosis of terminal liver cancer which
would have lead to a slow death by starvation and the likelihood of
institutional care. My own father died a "natural" death from congestive
heart failure. His multiple organ failures (kidney, heart, and lungs) lead
to hallucinations and increasing levels of frustration and angst as his
periods of lucidity waned. He was "made comfortable" with high levels of
morphine derivatives to enable him to rest "comfortably". In both cases
their deaths were hastened either by overt means or decisions not to intrude
with life supporting machines (kidney dialysis in my dad's case).
Is the refusal to utilize treatments that might cheat death for a period of
time any different from the decision to remove such life support when the
individual involved no longer can enjoy any quality from the "life" such
machines and intrusions provide? I don't think so. We all share one
commonality in this life - we will die. While few of us want to reach the
termination of life, the reality is that we all must.
When the death knell tolls we should each have the option to pursue
treatments that will delay our demise and also the ability to express
through living wills or direct discussions with our attending physicians and
our loved ones the circumstances under which we do not wish to continue with
life sustaining efforts. The question regarding removal of life sustaining
equipment begs a simpler question for me: has the life sustaining equipment
really replaced the failed organ meaning I can live my life in the same
manner as I did before the organ failed, or has it merely replaced the basic
function of the failed organ and in so doing has irreparably changed my
quality of life by either restricting my mobility or my ability to live
independently?
My dad suffered from congestive heart failure for several years after
successfully battling lymphoma with an aggressive chemotherapy regimen.
Basically, the patient was cured but at the expense of his heart function.
For a time he was able to live a fairly normal life through the
administration of several drugs to assist his heart in removing fluids from
his body. We enjoyed family vacations to Alaska and Europe with him after
his successful lymphoma treatments. His stamina wasn't 100%, but he was able
to enjoy his life. However, when he sustained major organ failure he was
sentenced to a bedridden existence. Kidney dialysis might have prolonged his
life, but it wouldn't have enabled him to walk, live in his home and enjoy
family gatherings ever again. In short, his lifestyle was altered in a way
that was unacceptable to him.
I wish as a society we could step back from our religious views, our
political posturing and our belief in the sanctity of life and consider for
just a moment that each of us will one day face our own moment of truth. How
do we want to pass from this existence? With compassionate medical care that
can be tailored to our own wishes or with archaic handwringing that leaves
everyone dissatisfied and puts medical practitioners in the position of
"playing god" or, perhaps worse, risking legal and criminal complaints for
compassionate actions?
In the ideal, the patient's wishes should be clearly communicated to family
and medical practitioners so the level and duration of care administered
will be consistent with those wishes. In this scenario your question is
easily answered. The doctor who "pulls the plug" has done so at the
patient's request and is merely allowing to take place what would have
already happened were it not for the medical intercession.
I came to your site from your blog and appreciate the opportunity to express
my opinion.
Sincerely yours,
Ric Enge
posted by Maurice Bernstein, M.D. @ 10:38:00 PM
5 comments
5 Comments:
I could not agree more.
I have watched more people than I care to say been "saved" by modern medicine, only to live shackled to machines with no quality of life what-so-ever. I think we need to think long and hard to what the word "living" really means...
i believe that life support should be an option, everyone has a fate, and if...we were meant 2 die then and there!would god give us the second chance of coming back?no i dont think so! accidents also happen, some people are faced with death before their time, and in my own personal opinion, if it can be prevented then so be it!!
I agree with NO extending life beyond its natural end. I have problems, however, when patients are placed "automatically" on analgesic drips for "comfort" when their brains are already NOT functional. I have seen that over and over, and I wonder... comfort of the physicians, other healthcare members and family? because the patient ALREADY is NOT feeling ANYTHING! That is because, everybody becomes too anxious when the hours go by and the patient is still breathing on her/his own!! This is clearly documented in the literature. and THAT constitute "killing"... let death arrive at its due time, not when it's convenient to us.
Morphine for the unconscious and unresponsive patient--this is a perfect example of unnecessary analgesic treatment that could easily lead to the iatrogenic (caused by the physician) premature death of the patient. I suspect that most physicians and nurses have enough experience to recognize when a patient is unconscious and unaware of pain and will not independently of the family prescribe analgesia. It is the family, gathered around the bedside, watching the last days breathing and other motor movements who misinterpret what they see as a patient in pain and agony and will request administration of more analgesia. And physicians often will give in to their requests since it is easier than attempting to educate them or arguing with them. It is the family who is being treated with the morphine and not the patient. One cannot argue that a resulting death is ethically excusable based on the so-called "double effect" since there was strictly no reason to administer the drug to benefit the patient in the first place. Is this the right thing to do? What do you think? ..Maurice.
A writer to my now inactive "Bioethics Discussion Pages" wrote the following to me today. ..Maurice.
You have to take the whole picture into perspective. As an ICU nurse, we fought to keep everyone going. I’ve had patients on vents for 3 weeks with trachs and they finally recovered, but their organs were functioning or only had an acute problem. We simply worked on each organ until they recovered. However, I’ve also had patients with MODs, who no matter how much you do you can’t make a liver have less damage or a bowel start working again or a pancreas etc etc. My uncle laid in a hospital after receiving an emergent LVAD in tons of pain due to MODs for 34 days. Though they had fixed his heart he had been too late getting to the hospital to get help and his organs went without adequate blood flow too long. Therefore, he could have set on a vent and the LVAD for years and never got any better just set in pain...he actually in his livid moments said he saw Heaven and you could watch him go completely relaxed and no wrinkles then the vent would breath for him and his eyes would shoot open in pure anger! As always in nursing you MUST take into consideration the entire picture. It’s not helping someone die if their already dying or dead and the machine is just doing the work... In my critical care experience I extubated many patients with poor prognosis or higher brain death and I do not feel I broke any ethical codes or killed anyone. We all have to die at some point.
I do feel that the CCU nurse caring for my uncle that left him on levophed, vasopressin etc for 34 days without pushing the MDs to have a real talk with the family about prognosis... I feel those nurses were horrible advocates!
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