First Things First (assess & treat for the following)

• Withdrawal of care means the withholding or discontinuing certain elements of treatment that prolong survival, while escalating and optimizing other treatment elements that provide comfort and pain relief.
• A biological, technological, or mechanical ability to sustain life does not always mean that it is the right thing to do, no matter what the circumstances are, for an individual patient
• Competent and informed patients have the right to refuse any (including life-sustaining) treatment.
• For incompetent patients, appropriate surrogates may make this decision, based on advance directives, previously stated wishes, known values, and the perceived general best interest of the patient.
• All members of the healthcare team should agree on the appropriateness in offering a withdrawal of care.
• Patients (if competent) and surrogate family members should be given ample time to make this decision.
• It is the physicians’ duty to provide their best judgment about the situation, make clear recommendations, and appropriately explain the process of withdrawal of care
• As in any medical intervention, informed consent (or assent) should be documented along with the formulated plan of action

Who might be a candidate?

• An almost infinite combination of factors weighs in considering withdrawal of care for a patient. These factors can be grouped as medical, ethical, moral, cultural, and personal. Therefore, each case is highly unique and has to be handled individually. Some of the specifics are as follows:
  • Disease process: It is important to look at the course of the disease, patient’s response to treatments administered, complications developed, and co-existing diseases present. A patient with metastatic cancer unresponsive to radiation and chemotherapy developing respiratory failure may leave little doubt about the appropriateness of withdrawal of life-sustaining treatment. Another patient, malnourished with anastomotic leak after esophagectomy, who develops an enterocutaneous fistula, several rounds of pneumonia, and sepsis might seem to have a number of potentially treatable conditions. The overall picture, rather than individual components of it, usually helps to form a better judgment.
  • Religious and Cultural Issues: Religion plays an important role in patients’ and family members’ decisions regarding withdrawal of care. Most religions regard life as a gift from God, and some may have open rules about what’s permissible and what is not. It is important to note that patients and families may belong a particular religion, but may not follow some of its tenets. Others may want to follow the recommendations of their chosen religion, but need to consult a religious representative of their particular faith. It is important to understand and respect those dynamics. Cultural differences are also evident in approach to decisions about end of life. In some cultures, a full disclosure of the prognosis to the patient is not considered appropriate, making a discussion of withdrawal of care impossible. In others, even brain death may not be considered the same as cardiac-circulatory arrest. Physicians’ duty is to remain sensitive to those cultural differences, refraining from passing judgment.
  • Problems with Predicting Prognosis: Finding an accurate scoring system for prediction of survival is one of the Holy Grails of critical care medicine. Unfortunately, none of the calculated scores (e.g. APACHE) have an acceptable positive predictive value of non-survival for the purpose of offering withdrawal of care. Physicians’ subjective assessments of the likelihood of death or poor functional outcome remain a valuable tool.
  • Physicians’ attitudes: Similar to patients and families, physicians’ approach to withdrawal of care is influenced by their professional, ethical cultural, social, moral, and religious backgrounds.

How can it be done?

• Family Meeting: Due to the effect of terminal illness on patients’ mental faculties, family members are the most likely decision makers for withdrawal of care. Meeting should be arranged in room separate from the ICU where interruptions are minimized. Presence of nurses and junior housestaff along with the attending physician is ideal. The attending physician should establish trust with the family before such a meeting takes place. At the meeting, medical information should be conveyed in an everyday language. Physician should show empathy and observe emotional moments. Families report less satisfaction when physician does most of the “talking.” Therefore, listening as well as silence as means of empathic communication are important.
• Formulating a Plan: Once an agreement is reached for withdrawal of care, the ideal situation is to stop all forms of life-sustaining support. It is unnecessary, confusing, and perhaps inhumane to go through a complete list of treatment modalities to stop. Common goal should be to maximize comfort and stop support to prolong survival. However, families may ascribe a symbolic significance to certain aspects of care and request their continuation. One common request, for example, is to continue nutrition and fluid administration. As long as these requests do not jeopardize comfort measures or prolong survival, they should be respected.
• Documentation of the Plan: Withdrawal of care is not a passive event but an active intervention. Therefore, an informed consent should clearly be documented in the chart. This is not a signed form, but rather a text stating the condition of the patient, discussion that took place with the family, and the family’s decision. If there are specific requests from the family that do not make clinical sense, these also should be documented. Finally, agreement between different attending physicians involved in the patient’s care should also be mentioned.
• Explaining the expected course: The physician should enlighten the family about what to expect in consequence to the implementation of the agreed plan. In some instances, where the patient is completely dependent on mechanical ventilation, it is easier to make predictions and offer an accurate timeframe for survival. In others, there is considerable variation and transfer of patient to a regular hospital room might be considered.