Wednesday, February 8, 2023
This activity is intended for physicians, physician assistants, nurse practitioners, nurses, pharmacists, students, and other clinicians who care for patients at the end of life.
The goal of this activity is to facilitate clinician decision making and implementation of decisions about life-sustaining treatments, particularly artificial nutrition and hydration, near the time of death.
Upon completion of this activity, participants will be able to:
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This activity is designed to be completed within the time designated on the title page; physicians should claim only those
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CME/CE Released: 3/24/2010
Valid for credit through: 3/24/2011
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Editor's Note:
This text has been excerpted and adapted from: Emanuel LL, Ferris FD, von Gunten CF, Von Roenn J, editors. EPEC™-O: Education in Palliative and End-of-life Care for Oncology (Module 11: Withdrawing Nutrition, Hydration Copyright The EPEC™ Project, Chicago, Ill, 2005). The EPEC™-O curriculum was produced by The EPEC™ Project, with major funding provided by the National Cancer Institute, and with supplemental funding provided by the Lance Armstrong Foundation.
Facilitating decision making and implementing decisions about life-sustaining treatments are essential skills for clinicians. Impediments to good care include misconceptions about legal and ethical issues, as well as unfamiliarity with the practical aspects of implementation.
This educational activity discusses approaches to determining and implementing treatment preferences in regard to the withholding or withdrawing of interventions. First, general principles and approaches are covered. Next, specific issues of artificial nutrition and hydration are covered in more detail. These issues frequently present a challenge in routine practice, and they also provide an example of how to discuss withholding or withdrawing treatments in general.
All clinicians play an essential role in defining and implementing the plan of care, and providing continuity of care as the goals evolve and change over time. The physician or possibly the nurse practitioner or physician assistant will often take the lead in initiating discussions about life-sustaining treatment, educating patients and families, helping patients and families deliberate, and making recommendations about the treatment plan. As part of this role, the clinician is responsible for ensuring that the patient's wishes are documented and supported by the appropriate medical orders. Advance directives may be in place and helpful, but may not necessarily make clear how to translate general goals or treatment preferences into treatment of the present medical conditions. Consequently, it is critical that physicians, nurse practitioners, and physician assistants all have the knowledge and skills necessary for discussions, negotiations, and implementation of decisions related to life-sustaining treatments.
Other members of the healthcare team play an essential role in formulating and implementing the plan of care around issues of artificial nutrition and hydration, and will need to be skilled in the issues related to these decisions as well. Nurses, social workers, chaplains, speech therapists, and nutritionists/dietitians share in the responsibility of educating the patient and family about artificial nutrition and hydration so that the patient and family can make an informed decision. Nurses and other members of the healthcare team are charged with implementing treatment orders.
Making decisions about artificial nutrition and hydration is fraught with intense emotions, and the entire healthcare team needs to be able to support patients and families emotionally and spiritually as they struggle with the implications of decision making and the realities of disease progression.
All states in the United States have statutes covering issues related to withholding or withdrawing life-sustaining treatments.
The Quinlan case (1976) established that artificial nutrition could be withdrawn even from a patient in a persistent vegetative
state.[1] In 1983, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research
found that no treatments, including artificial nutrition and hydration, were obligatory.[2] This was confirmed in the US Supreme Court decision on the Cruzan case in 1990, which established that artificial hydration
and nutrition are like other life-sustaining
treatments.[3] It was upheld again in the Florida courts in the case of Schiavo in 2005.
It is also legal and ethical to withhold or withdraw nutrition and hydration for the patient who lacks decision-making capacity.[4] States may differ in the degree of evidence that is required if the patient lacks decision-making capacity. For example, in New York and Missouri, there must be "clear and convincing evidence." In the other states, substitute decision makers can make the decision.
Institutional policies of many hospitals or other healthcare institutions tend to include considerations, perhaps drafted by ethics committees, to protect patients' rights and interests and considerations, or possibly crafted by risk management officers to protect the institution from risk. Institutional policies are often written in response to the general perceived legal imperative to, when in doubt, provide treatment to prolong life. Institutional policies may or may not be in the best interest of a particular patient. If the appropriate goals of care are other than "life at all costs," then the written plan of care needs to be specific enough to accomplish the intended goals.
Emergency medical technicians are regulated by statute, and sometimes by city ordinance. Although requirements vary, in general, emergency medical technicians are required to provide all resuscitative and life-prolonging treatments unless a do-not-resuscitate (DNR) order, which complies with state-specific ordinances, is in place to the contrary.
Although only physicians and advanced practice clinicians can write orders, it is the responsibility of the entire healthcare team to ensure that the patient's wishes (or parents' if the patient is a child) are followed across care settings. In the hospital, one major study demonstrated that the majority of patients in intensive care unit settings die without attention to issues of life-sustaining treatment.[3] Many of these patients have undergone some form of invasive medical treatment against their previously stated wishes.[5]
All too often, patients are transferred to the acute care setting, where inappropriate life-sustaining measures are administered
because the appropriate treatment plan and medical care orders have not been completed and placed in the patient's chart.
One study demonstrated that fewer than 25% of advance directive orders were carried over from the nursing home to the acute
care
hospital.[6] The fact that medical care orders may not transfer across settings (eg, nursing home, ambulance, acute care hospital) also
exacerbates the problem.
Table 1. Life-Sustaining Treatments
| Resuscitation | Diagnostic tests |
| Artificial nutrition and hydration | Elective intubation |
| Surgery | Antibiotics |
| Dialysis | Other treatments |
| Blood transfusions, blood products | Future hospital or intensive care unit admissions |
There is a wide range of life-sustaining treatments that may be considered for an individual patient and family. These include
cardiopulmonary resuscitation, elective intubation and mechanical ventilation, surgery, dialysis, blood transfusions or administration
of blood products, artificial nutrition and hydration, diagnostic tests, antibiotics, other medications and treatments, and
future hospital or intensive care unit admissions.
After determining the general goals of care, the clinician discusses specific treatments with his/her patients and families and whether those treatments will possibly help achieve the patient's overall goal. Asking a patient's preference for a scenario-specific invasive intervention vs an alternative noninvasive intervention may help the clinician to get a general idea of a patient's priorities for making treatment decisions. Decisions about surgery and antibiotics are often strongly predictive of other invasive and noninvasive decisions, respectively.[7]
Culture plays a role in decisions to withhold or withdraw care. For example, many studies have shown that nonwhite patients are less likely than white patients to agree to DNR orders or to withhold or withdraw care, and are less likely to have advance care directives.[8-10] In Asian cultures, filial piety, the obligation of children to care for their parents in gratitude for the parent's caring and sacrifices, is a central value. Making a decision to withhold or withdraw life support from a parent may be seen as unfilial.[11] If the integrity of the family as a whole is valued more than the wishes of an individual family member, even the patient who would not want life support may expect the family to do everything possible to prolong his or her life. To do otherwise would bring dishonor on the family.
Different cultures may have varying views of the role of suffering. Although many healthcare providers may support withholding life support at the end of life as a compassionate act that prevents unnecessary suffering, not all patients share this value. Some cultures view suffering as redemptive and something to be endured as a test of faith rather than avoided. The idea that only God knows when it is time to die may also affect how patients view the use of life-sustaining therapies.
Various religions have espoused specific opinions about the use of artificial hydration and nutrition. Most teach that when death is inevitable and not due to the absence of hydration or nutrition, withholding both can be appropriate. However, some religious leaders teach that human beings must do all in their power to prolong life. In situations of conflict, it is wise to engage leaders or teachers of the religious faith in question.
