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Withholding Treatment

Ethical Issues Involving Withdrawal or Withholding Treatment

In this essay we examine the impact of withholding and withdrawal of treatment from a nursing perspective and examine the ethical issues involved. When a cure is absolutely impossible certain life sustaining medical treatments such as cardiopulmonary resuscitation, ventilation, nutrition and hydration, dialysis, transfusions, and antibiotics may have to be withdrawn or withheld (Derse, 2005). Recent media attention on the case of Terri Schiavo has successfully highlighted the ethical, legal and social issues of withdrawing and withholding treatment. Konishi et al (2002) discuss the ethics of withdrawing artificial food and fluid from terminally ill patients bringing in the dilemma on end of life issues and whether life of patients could be ended intentionally by stopping or withdrawing treatment.

Withdrawal of food and fluid from terminally ill patients is a growing ethical issue and concerns patients, families, and nurses as well. The study sampled 160 nurses and they completed a questionnaire that included forced-choice and open-ended questions and the act of withdrawing treatment was supported by nurses only for two specific conditions - if the patients requested it and if it relieved the patient of his or her suffering. However, it is widely agreed that doctors' orders, family's requests or even the patient's advanced age could not and should not ethically justify the act of withholding or withdrawing treatment. The study suggests that apart from the direct clinical issues concerned, the ethical, social and cultural factors seem to play a significant role in any decision of withdrawing or withholding treatment.

In this essay we discuss the implications of withdrawing treatment and the role of nurses in this regard. We also discuss the ethical, social and legal issues involved in withholding treatment and the challenges faced by nurses providing end-of-life care.

Withdrawing Treatment, End-of Life Issues and Dilemma

Fartoukh et al(2005) argue that decisions to withdraw and withhold active life support treatment in situations where there are hopes of recovery or improvement remain a difficult prospect for critical care specialists and for families and the difficulty is not always understood by members outside the family of the patient or hospital staff. The report by Fartoukh et al describes the consequences and implications of terminal extubation from terminally ill patients. Terminal extubation is the permanent removal of life support treatment and is a method of withdrawing ventilator support.

The records of patients who died in intensive care units after a decision to withdraw life support by stopping artificial ventilation were analyzed. Patients with irreversible neurological damage were subjected to extubation or removal of artificial ventilator support systems but this was done only after standardized collective decision making process and a consensus was reached to end support and withdraw treatment. Following extubation and treatment withdrawal, all patients died within 3 days.

The authors reiterate that terminal extubation reinforces the transparency of end-of life decision in intensive care units and highlights the aspects of aggressive treatment provided by critical care specialists. The study highlights the ethical dilemma faced by nurses and healthcare workers, should a person in prolonged and irreversible respiratory illness be withdrawn from treatment or artificial medical aids? The authors argue that several advantages and disadvantages mark the practice of extubation although extubation may be justified in case of irreversible neurological damage.

Ethics is however a general term used to describe the science or study of morality and is also considered a moral philosophy of what is good and bad, right or wrong. Nursing practice is often guided by 'deontological' ethics which is associated with the moral code of duty and states that morality forbids or permits certain actions. This is often contrasted with consequentialist or teleological theories of utilitarianism that maintain that whether an action is right or wrong is dependent on the consequences and the circumstances of the act.

The underpinnings of all ethical behaviour are generally the principles of autonomy, beneficence, non-maleficence and justice (Hudson, 1999). According to Hudson (1999), these four principles have been labeled as 'the mantra of bioethics'. These theoretical considerations do seem to influence nursing ethical practice and decision making highlighting respect for autonomy and justice (Beauchamp and Childress, 1994).

Besdine (1983) bring out the ethical issues through the differences in clinical care and end of life issues in severely impaired nursing home residents and those faced by patients in acute hospital care. Besdine points out that 'do not resuscitate' orders are not of central importance in the nursing home although for the individuals who are considered for treatment and withdrawal of treatment, decisions about limiting routine treatments and whether treatments should include hospitalization are all crucial. The paper argues that establishing an ethical issues team to tackle end of life issues can serve as an important means of increasing awareness about the ethical issues in patient care especially during end of life periods and can help with dealing of difficult issues like withdrawing treatments more effectively.

Nurses' attitudes to euthanasia and end-of life ethical issues have been studied by Verpoort et al (2004) and they report that there are large differences with respect to the percentage of nurses who are in favour and not in favour of euthanasia. Age, religion and nursing specialty seem to influence nurse's opinions on euthanasia significantly. The paper highlights the arguments for and against euthanasia and suggests that the arguments for euthanasia have to do with quality of life, dissatisfaction with the present situation and health condition and respect for autonomy. Arguments against euthanasia include a normal human right to proper natural death, belief in positive results from prolonged palliative care, religious objections to intentional termination of life, and fear of abuse

The nurses' perspectives were studied in detail and according to this report; nurses mention the need for more palliative training, their difficulties in taking a specific position or having a specific opinion for or against euthanasia or withdrawal of treatment. Nurses also point out that they do face considerable difficulties in their desire to express freely their ideas on euthanasia or termination of treatment. The authors are however emphatic in their suggestion that nurses should voice out their opinions on end of life issues and a proper discourse should be encouraged as nurses offer a contextual understanding of euthanasia, withdrawing treatments and requests to die as they have real first hand knowledge and experience with people who are facing death or possibilities of death.

Nurses play a very important role in end of life care and they must be prepared to care for patients at the end of life while facing a multitude of complex issues relating to the physical, psychological and spiritual needs of patients (Davis, 1991). End of life and palliative care provided by nurses not only aim to control symptoms but is also expected to address the overall psychological and social needs of the patients who face increasing dilemma over life and death decisions. Bialk (2004) emphasize that nurses should use a decision framework to be better prepared to assist patients in exploring options for end of life care and for withdrawal of treatment.

A more ethical alternative to euthanasia or physician assisted suicide is voluntary refusal of food and fluids (VRFF) in which the patient can voluntarily refuse life sustaining treatments.

Harvath et al(2004) have studied nursing attitudes towards voluntary refusal of treatment and the results of this study show the attitudes of nurses and social workers towards VRFF and compares this with their attitudes towards physician assisted suicide or PAS. The study showed that hospice workers expressed support for patients who choose to hasten their death by VRFF although they are less supportive of PAS or physician assisted suicide. This suggests that nurses have different perceptions for VRFF and PAS and the results of this study proving nurses' attitudes may have important implications for nurses and social workers who are involved in end of life care of patients wishing to hasten their deaths by termination of treatment.

In a similar vein Snelling (2004) discuss that there have been considerable distinctions between acts and omissions, killing and letting die with opponents of euthanasia justifying cases of passive euthanasia while forbidding all active euthanasia. Snelling argues that forbidding euthanasia completely may be theoretically inconsistent. He analyses the moral problems associated with withdrawal of treatments within the framework of the principles of biomedical ethics. The legal status of withdrawing treatment and consequent killing is based on a deontological position against deliberate killing and cannot be overturned even if contrary cases are cited. For allowing passive forms of euthanasia, three pairs of concepts have been distinguished by Snelling and these are acts and omission, killing and letting die and using ordinary and extraordinary means of death.

Several issues are thus important in considering nursing care for patients or families of patients wishing to withdraw treatments or considering euthanasia. A conceptual framework may be necessary for nursing professionals to understand end of life care as a unique challenge and experience in the profession. The spiritual domain of a human being becomes very important at the end of life and forms the core of psychological, physical and functional domains of a person highlighting that the integrity of a human person is an organizing concept and takes up a significant role in later life.

This sort of care framework considering physical, social, psychological and overall spiritual aspects of a person goes beyond all other frameworks by including the relationship of the healthcare professionals, healthcare organization, and nursing professionals to the integrity of the person. Issues that gain importance are quality of life, physical and psychological comfort of the patient, patient decision making methods, and achievement of life goals. Within a multicultural society, the cultural dimensions of being human, and end of life needs are also considered both during acute phases of terminal illness and prolonged frailty of health due to advanced age.

The challenges of palliative, end of life care especially in cases where patient seek withdrawal of treatment are thus many and can be categorized as follows:

1. Ethical issues such as whether voluntary or physician assisted death should be supported as opposed to natural death (Melia, 1992)

2. Improving quality of life and addressing psychological, physical, social and spiritual needs of patients

3. Justifying death, or withdrawal of treatments to family members, patients, social, religious and legal groups and opponents of euthanasia

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Conclusion:

In this study we discussed the ethical considerations of withdrawing and withholding treatment in terminally ill patients from a nursing perspective and discussed several evidential studies that highlight the dilemma of nurses with regard to physician assisted deaths. In most cases it has been seen that voluntary withholding or withdrawal of treatments requested by patients may be generally better supported by nurses than physician recommended deaths in which fluid and food are stopped for terminally ill patients. For future practice, other considerations for treatment of terminally ill patients are taking care of their spiritual and psychosocial needs as well as sustaining a standard quality of life to prepare them for a painless death. Some studies have suggested setting up of ethical team to consider such issues within the clinical setting whereas some others have emphasized the importance of the opinions of nurses to justify or oppose withdrawal and withholding treatment in patients who are close to death. In most cases, the patients willingness to die and death as a means of reducing pain or suffering have been considered as important by nurses and remain the main causes of withdrawal and withholding treatment to hasten death. However, controversies such as the Terri Schiavo case will continue to appear as major ethical, social and legal issues are involved in the termination of treatment.

Bibliography:

Besdine RW. Decisions to withhold treatment from nursing home residents. J Am Geriatr Soc. 1983 Oct;31(10):602-6.

Beauchamp, T., & Childress J.F. (1994) Principles of biomedical ethics (4th ed.). New York: Oxford University Press

Bialk JL. Ethical guidelines for assisting patients with end-of-life decision making. Medsurg Nurs. 2004 Apr;13(2):87-90.

Davis, Anne J. Ethical dilemmas and nursing practice / Anne J. Davis, Mila A. Aroskar. 3rd ed. Norwalk, Conn. : Appleton-Century-Crofts ; London : Prentice-Hall, 1991.

Derse AR.Limitation of treatment at the end-of-life: withholding and withdrawal. Clin Geriatr Med. 2005 Feb;21(1):223-38, xi. Review.

Konishi E, Davis AJ, Aiba T. The ethics of withdrawing artificial food and fluid from terminally ill patients: an end-of-life dilemma for Japanese nurses and families. Nurs Ethics. 2002 Jan;9(1):7-19.

Fartoukh M, Brun-Buisson C, Lemaire F. Terminal extubation in 5 end-of-life patients in intensive care units Presse Med. 2005 Apr 9;34(7):495-501.

Harvath TA, Miller LL, Goy E, Jackson A, Delorit M, Ganzini L. Voluntary refusal of food and fluids: attitudes of Oregon hospice nurses and social workers. Int J Palliat Nurs. 2004 May;10(5):236-41; discussion 242-3.

Hope, R. A. Medical ethics : a very short introduction / Tony Hope. Oxford : Oxford University Press, 2004.

Hudson, S Ethics for Alternative Paradigms: An Exploration of Options Graduate Research in Nursing Volume 1, Number 2 ,October / November 1999

McClain K, Perkins P. Terminally ill patients in the emergency department: a practical overview of end-of-life issues. J Emerg Nurs. 2002 Dec;28(6):515-22.

Melia, Kath M. Everyday nursing ethics / Kath M. Melia. Basingstoke, Macmillan, 1992, c1989.

Snelling PC. Consequences count: against absolutism at the end of life. J Adv Nurs. 2004 May;46(4):350-7.

Verpoort C, Gastmans C, De Bal N, Dierckx de Casterle B. Nurses' attitudes to euthanasia: a review of the literature. Nurs Ethics. 2004;11(4):349-65.

Terri Schiavo story in the bbc http://news.bbc.co.uk/2/hi/americas/4399011.stm

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