Withholding or Withdrawing Life Support

Any fully informed patient with decision-making capacity has the right to accept or reject or discontinue (withhold or withdraw) any treatment or procedure even if it may be life-sustaining medical treatment (LSMT) or life saving. A patient need not be imminently dying for this to apply. Also, patients in any phase of a terminal illness may request or provide for withdrawal or non-institution of such therapy. Both withdrawal and withholding requests are treated as ethically equivalent actions.

Life-sustaining medical treatment (LSMT) is any treatment that serves to prolong life without reversing the underlying medical condition. LMST may include, but is not limited to: mechanical ventilation, renal dialysis, chemotherapy, antibiotics, and artificial nutrition and hydration.

A terminal condition means an incurable and irreversible condition caused by injury, disease, or illness that, within reasonable medical judgment, will result in death within a reasonable period of time and where the application of LSMT serves only to prolong the process of dying.

A patient who does not have decision-making capacity and/or is in a permanent unconscious condition, has these same rights, they are expressed through advanced directives, by a proxy, or by the actions of another person acting in the patient’s best interest.

Permanent unconscious condition means an incurable and irreversible condition in which the patient is medically assessed within reasonable medical judgment as having no reasonable probability of recovery from an irreversible coma or a persistent vegetative state.

1. The attending physician should determine the patient’s decision making capacity when Life Sustaining Medical Treatment (LSMT) is deemed necessary. If the patient does not have this capacity, then the physician should follow a written advance directive (if available) or consult a duly appointed health care proxy. In the absence of an advance directive or proxy, the physician should consult with (in this order): a court-appointed guardian, spouse, adult children, parents, adult siblings, grandparents or a significant other. (For children, parents, siblings: when more than one person, all must agree.)

2. When the lack of decision making capacity is related to mental or psychological impairment or developmental disability, the lack of capacity should be confirmed by a consulting physician or a professional with the necessary expertise.

3. The nature of the treatment, the reason for the therapy, the risks and benefits, any alternative therapy and prognosis, are to be explained.

4. The physician will write the appropriate orders and progress notes in the medical record. These notes should address the following:

• For a patient with decision making capacity: State the presence of capacity and basis of the conclusion. Document the nature of the discussion with the patient regarding the diagnosis, prognosis, risks and benefits and outcome of withholding or withdrawing, or refusal of therapy. Document the conversations with the family or a significant other. Inform the patient of his/her right to change this directive.
• For a patient without decision making capacity:  State the nature of the incapacity. List the wishes of the patient through an advance directive, statements, or letters. State the name and relationship of the proxy. Give the nature of the conversation about the withholding or withdrawal of the treatment. List the names and the professions of the people who partook in the discussion. Define the care plan. Maintain the appropriate medical records.

5.  Patients who have had LMST withheld or withdrawn are to be supported with adequate orders for comfort care, pain management, and emotional and spiritual support by the interdisciplinary team.

1. The attending physician assesses decision-making capacity. If it is not clear that the patient lacks decision-making capacity, confirmation by another physician shall be obtained.

2. A decision to forgo LSMT is acceptable if a treatment or procedure is futile or will only delay a dying process as ascertained by the attending physician. Futile treatment in a patient with serious, irreversible illness or condition, is any treatment that is:

• Unlikely to provide benefit that the patient has the capacity to appreciate, or
• Highly likely to require permanent dependence on medical care where the burdens greatly outweigh any chance of success or benefit to the patient.

3. Recognizing our role as a critical access hospital, patients in a suspected Persistent Vegetative State (PVS) or an irreversible coma would be transferred prior to the need to provide confirmation of Persistent Vegetative State (PVS) or an irreversible coma. But we would comply with patient wishes forgoing LMST if there was agreement with the patient’s advanced directives/proxy/and the attending physician.

4. Patients with irreversible conditions in which the risks and burdens of LSMT outweigh any benefit to the patient may have these procedures withdrawn or withheld by the attending physician.

5. In cases declared futile, if the physician feels unable to honor a patient’s/family’s wishes about the use of LSMT, he/she should transfer the case to a doctor who will, or seek consultation as outlined in the Conflict Resolution section (below).

Conflicts may arise, and ideally are resolved via discussion between identified parties. If conflict resolution is not accomplished successfully, the following avenues are available:

• Clinical staff may activate the policy for “Ensuring Appropriate Patient Care” (in the Administrative Policy Manual) or seek consultation from Nursing Executive(s) and/or the Clinical Ethics Committee.
• Medical staff may seek consultation from Chief of Service, Chief of Staff, the Clinical Ethics Committee, another physician, or Nursing Executive(s) as needed.
• Patients/families may be referred to Department Manager or Nursing Executive(s). If a conflict remains unresolved, arrangement may be made to have the patient’s care transferred to another physician or to another institution as necessary. If such action is requested by patient/family, assistance will be provided by hospital staff as needed.