Refusal of Life-Sustaining Treatment



Refusal of Life-Sustaining Treatment





A defining characteristic of Western medicine over the past three decades is the formalization of the right of patients to refuse unwanted medical therapy including life-sustaining treatment (LST). In the United States, the decision to withhold or withdraw LST has evolved from being physician-centered to being patient-centered.1 Until around 1990, the issue was conceptualized by defining those circumstances in which a physician was ethically and legally permitted to discontinue a patient’s LST. Currently, however, the topic is conceptualized as informed refusal: the application of the doctrine of informed consent that permits all patients to refuse tests or treatments they wish to forego, even if they will die as a result of their refusal. In nearly every instance, the physician must discontinue the unwanted treatments, including LST, once a patient has validly refused them. Thus, it is no longer accurate to consider the topic as the physician-centered “termination of LST” but rather as the patient-centered “refusal of LST,” acknowledging that the decision to forego LST ultimately is the patient’s to make and, when valid, the physician’s to carry out.


ETHICAL AND MEDICAL ISSUES

The ethical basis of the right to refuse LST arises from our respect of patients’ autonomy and self-determination. Only patients ultimately know and are authorized to decide what treatments best satisfy their health values and goals. The doctrine of self-determination respects the fact that values and goals of treatment may differ between physicians and patients, and may vary among patients. It is the patient’s own values and goals of treatment that should be granted primacy.2 The patient’s ethical right to consent to or refuse therapy is not extinguished if the patient loses the cognitive or communicative capacity to make a medical decision. The right endures and is transferred to a surrogate decision maker to exercise on behalf of the patient.

The patient’s right to refuse therapy is operationalized through the doctrine of informed consent, as explained in chapter 2. The criteria of informed refusal are identical with those of consent. First, adequate information—information that a reasonable person would need to know to be able to consent or refuse—must be conveyed by the physician to the patient. Patients deciding to accept or refuse LST need to know their diagnosis and prognosis, the available treatments, their likely beneficial and harmful effects and outcomes, the physician’s treatment recommendation, and the reason for the recommendation. As is true in any consent discussion, consent is a process, not an event. Proper informed consent and refusal requires thoughtful dialogue that proceeds over time, ideally in a calm, unhurried environment, with the proper ambience for patients’ and families’ questions and fears to be adequately addressed.

Second, the patient should possess the cognitive and communicative capacities to understand, achieve, and communicate a decision to consent or refuse. Many critically ill and dying patients lack either the cognitive capacity to
provide consent or the ability to communicate a decision. If the patient lacks these capacities, the physician should conduct an identical conversation with the patient’s lawful surrogate decision maker, a third party who has been granted the authority to consent or refuse on behalf of the patient. Informed consent or refusal becomes a more difficult process when the patient loses capacity because the physician and the surrogate both must attempt to divine and carry out the true wishes of the patient.

Third, although physicians are permitted to make strong treatment recommendations, they should not coerce patients or surrogates into accepting medical treatment. The line between a strong recommendation and coercion at times may be hard to draw. Physicians should not threaten patients or surrogates, not exaggerate facts, and not communicate nonfactual circumstances which no person reasonably could resist.3

The physician and the competent patient create a decision-making dyad in a process called shared decision making. In the shared decision-making model, the clinician contributes specialized knowledge, training, and experience regarding medical diagnosis, prognosis, and treatment options and their outcomes; the patient contributes a unique knowledge of personal values, preferences, and health-care goals. Together, they reach a mutually agreeable medical care plan that represents the best treatment for that patient. The shared decision-making model does not abdicate complete control of health-care decisions to patients; it merely acknowledges that only patients can define what treatment options ultimately are best for themselves.4

When the patient loses cognitive or communicative capacities, the patient’s lawful surrogate decision maker joins the patient-physician dyad to form a decision-making triad. As discussed in chapter 4, there are accepted standards for surrogate decision making. The surrogate decision maker should strive faithfully to represent the wishes and values of the patient. First, the surrogate should communicate the expressed wishes of the patient, if known, including those in valid written advance directives.5 If the patient’s specific wishes are unknown, the surrogate should attempt to reproduce that decision the patient would have made, by employing the preferences and values of the patient using the doctrine of substituted judgment. If the surrogate does not know the values of the patient, the surrogate should balance the burdens and benefits of treatment to the patient and render a best interest judgment.6

Physicians should identify barriers to proper decision making and attempt to surmount them to enhance the quality of patients’ and surrogates’ decisions. A patient’s desire no longer to be a burden to loved ones is a common motivation for refusing LST.7 Many critically ill and dying patients experience potentially reversible degrees of depression that may influence their decisions to consent to or refuse LST. Not surprisingly, the presence of psychological distress, including depression, has been found to be responsible for decisions of dying patients to terminate LST and to request physician-assisted suicide.8 The longer survival of non-depressed than depressed ALS patients is at least partially the result of the latter’s earlier refusal of LST.9 The question of whether severe depression invalidates a patient’s refusal of LST is difficult because the severity of depression comprises a continuum and not all depressed dying patients are thinking irrationally when they wish to die sooner.10 Physicians’ diagnosis and treatment of reversible depression can improve the quality of life and decision making of terminally ill patients.11

Not all ostensibly rational decisions reached by patients or surrogates to continue or discontinue LST are completely rational. This fact imposes an ethical duty on physicians to try to identify sources of irrational thinking and to help correct them. Denial represents the principal irrational thought process of dying patients. The dying patient’s acceptance of the inevitability of impending death takes time and can be assisted by compassionate counseling from physicians. It is often difficult for physicians to strike the ideal balance between maintaining hope and providing accurate prognostic information.12 Physicians should try to understand and respond to patients’ fears. Most patients need reassurance
that they will not suffer and that their physician will loyally care for and not abandon them as they become sicker. Physicians also can reassure them that their treatment preferences and wishes will be carried out faithfully.

Some patients dying of neurological diseases continue to maintain intact cognition but suffer severe paralysis or other physical impairments that interfere with efficient communication. This is a common situation in the ALS patient as discussed in chapter 14. Neurologists should try to enhance patients’ communication capacities to permit them to continue to participate maximally in clinical decisions. Assistance from occupational therapists trained in computer communications technology can be requested to design an efficient communication system.13

Many physicians express more difficulty stopping LST that already has been started than not providing LST in the first place because they conceptualize discontinuing ongoing LST as “killing” the patient. Although the psychological grounds for this difficulty are understandable because of the intuitive distinction between the omission and commission of an act, it is not a defensible ethical distinction. A broad consensus holds that there is no important ethical or legal difference between withholding and withdrawing LST. Once LST has been refused by a competent patient or by the lawful surrogate of an incompetent patient, physicians generally must not start it, or must stop it if it has been started.14


Do-Not-Resuscitate Orders

The earliest permissible withholding of life-sustaining treatment was the Do-Not-Resuscitate order. Closed-chest cardiopulmonary resuscitation (CPR) was described in 1960 as an emergency treatment designed to save the lives of patients who had suffered cardiopulmonary arrest.15 Within a decade, CPR techniques had become standardized and were taught to physicians as a routine part of medical care. The American Heart Association and other groups helped teach CPR to laymen so they could initiate and continue the therapy until the patient with an out-of-hospital cardiac arrest reached medical attention.16 Hospitals organized resuscitation teams to respond rapidly to cardiac arrest “codes” in the hospital and perform CPR. By the late 1980s, it was estimated that CPR was being attempted on one-third of patients dying in American hospitals and on countless people who collapsed outside of hospitals.17

Cardiopulmonary resuscitation became routine medical treatment because of the obvious benefits of restoring heartbeat and breathing and thus rescuing the lives of patients suffering sudden cardiopulmonary arrest. The intent was to restore patients to their previous health. CPR was neither developed nor intended to prolong the lives of patients who were dying inexorably of terminal illness. Yet the routine, mandatory nature of performing CPR led physicians and others to perform it in a rote manner in instances of obvious terminal illness for which it was neither intended nor effective.

Beginning in the late 1960s, physicians became increasingly aware of the uselessness and undesirability of performing CPR on irreversibly dying patients. But because performing CPR had become obligatory treatment, physicians were required to attempt it when a patient suffered a cardiopulmonary arrest. The knowledge that CPR was futile in these cases led physicians to perform “slow codes” (half-hearted attempts to perform CPR), while realizing that it was ineffective and senseless. In these cases, the resuscitation team went through the motions of CPR out of a sense of obligation rather than from a belief that it would produce any therapeutic benefit to the patient or was appropriate.18

Thereafter, the concept was advanced that it was wrong to attempt CPR on all patients suffering cardiac arrest. Certain patients could be identified in advance who were clearly so ill and irreversibly dying that CPR would almost certainly fail. When physicians identified such patients upon admission to the hospital, or during a hospitalization, they could write Do-Not-Resuscitate (DNR) orders to prevent them from receiving futile and medically inappropriate CPR attempts. Some institutions preferred to call them Do-Not-Attempt-Resuscitation (DNAR) orders to clarify what the order actually signified.19


The drafting and implementation of hospital policies permitting physicians to formally write DNR orders lagged behind the need for these policies. In hospitals in which DNR orders were not permitted, physicians communicated the DNR decision verbally to nurses who then annotated the decision on the chart in pencil (thus permitting its easy erasure) or employed one of a series of other informal mechanisms to signify DNR status, such as noting the decision in chalk on a blackboard or placing a colored dot on the patient’s medical record.20 Not until a decade later had most hospitals implemented DNR policies permitting physicians to formally and openly write DNR orders.

Thereafter, the issue of providing explicit consent or refusal for CPR began to receive attention.21 As is true in other instances of emergency medical care, consent for CPR is presumed. Currently, for cardiopulmonary arrests occurring in the hospital, CPR is performed by default unless there is a specific DNR order prohibiting it. Only competent patients and the lawful surrogate decision makers of incompetent patients can authorize physicians to write DNR orders. Unlike most treatments that require a patient or surrogate’s valid consent to receive them, CPR requires a valid refusal or it will be performed automatically under the doctrine of presumed consent. This inversion of the consent process is responsible for some of the confusion and unique clinical-ethical issues of DNR orders. The special problems of DNR orders in children have been explored in ethical and legal detail.22

Patients who suffer out-of-hospital cardiac arrests have a 3% to 14% chance of survival to hospital discharge whereas patients who suffer in-hospital cardiac arrests have a 10% to 20% chance of survival to hospital discharge.23 Embedded within these figures, however, are important variables: CPR success rates vary as a function of the type and severity of the patient’s underlying illness. In two of the largest published studies of in-hospital CPR encompassing over 26,000 attempted cases, 16% of patients survived to be discharged from the hospital.24 However, the 16% figure was a mean of all recovered cases including those for which the prior probability of CPR success was high and other cases for which it was low. For example, in two studies of CPR success rates, none of the patients with metastatic cancer, acute stroke, sepsis, or pneumonia on whom CPR was attempted survived to hospital discharge.25 Similar finding have been observed in other studies.26 There is a debate about whether advanced age is an independent risk factor for CPR success.27

In addition to survival as an end-point of CPR outcome studies, quality of life has been examined. Of those patients surviving hospital discharge after CPR, 93% were found to be alert and oriented, 11% to 44% had evidence of “neurologic impairment,”28 and less than 3% had gross impairment of mental status. Most patients, however, had diminished global function compared to pre-hospital functional status.29 The majority of patients with poor outcomes did not survive until hospital discharge.

Nearly all hospitals now have DNR policies based on local practices and DNR guidelines published by national bodies.30 The remaining ethical and practical questions in writing DNR orders include: (1) When can physicians write DNR orders unilaterally—without consent of patient or surrogate, or even against the patient’s or surrogate’s wishes—on the grounds of medical futility? I discuss this issue in chapter 10. (2) How do partial DNR orders fit in a limited aggressive therapy order? (3) Should physicians temporarily suspend DNR orders when patients require general anesthesia and surgery? (4) How can hospital DNR orders be maintained during home care following discharge to prevent unwanted CPR?31

A DNR order in most hospitals prohibits chest compressions, defibrillation, endotracheal intubation, mechanical and mouth-to-mouth ventilation, and the administration of vasopressor and cardiac stimulant drugs. In some cases, patients and surrogates do not want blanket DNR but wish to permit one or more of these therapies in case of cardiopulmonary arrest. For example, some patients expressly refuse intubation but will permit defibrillation and the administration of cardiac drugs. They may request a “Do-Not-Intubate” order, which is a common partial DNR order. It is best not to regard DNR automatically as a
blanket order but to discuss the separate elements of CPR with patients and surrogates to permit a tailored order that prohibits all or part of the array of CPR techniques. Some scholars have called this a “limited aggressive therapy order”32 or a partial DNR order.33 Ideally, the partial or full DNR order will arise from an individualized care plan negotiated with the patient or surrogate that is correlated with the patient’s health-care goals and preferences for resuscitative treatment.

DNR orders indicate only that the elements of CPR will not be performed. Yet, there is widespread misunderstanding among lay persons and some professionals that once a patient is labeled “DNR” the overall aggressiveness of treatment should be lessened. Although this belief is technically erroneous, it has been found to be true in practice. In several studies, the presence of a DNR order was correlated with an overall lack of aggressiveness of treatment.34 Most hospitals have developed limitation of therapy orders or palliative care orders to accomplish limiting aggressive therapy in addition to DNR orders. These orders should be used if the plan is to limit treatment and the DNR order reserved solely to refuse CPR.

Occasionally, patients with DNR orders require surgery and general anesthesia. For example, a patient with widely metastatic cancer may require an emergency operation for acute cholecystitis or bowel obstruction. The decision to proceed with surgery in such cases usually is based on the palliative goals of surgery: the procedure will promote comfort in the remaining weeks or months of life 35 General anesthesia usually requires endotracheal intubation and mechanical ventilation, which otherwise is forbidden by a blanket DNR order. Surgeons and anesthesiologists may ask the patient or surrogate temporarily to suspend parts of the DNR order during the peri-operative period to permit the successful completion of the procedure.36 There should be additional discussions over whether an intraoperative cardiac arrest will be treated or whether prolonged mechanical ventilation will be performed if needed.37

There are generally accepted guidelines to settle these questions and negotiate a temporary suspension or modification of the DNR order during the peri-operative period. The guidelines require the surgeon or anesthesiologist to conduct a pre-operative conversation with the patient or surrogate during which the goals of treatment are discussed and the means to achieve those goals are agreed upon. The patient or surrogate may or may not grant permission for the DNR order to be modified or rescinded temporarily. If a suspension or modification of the DNR order is made, the terms and time limit of the suspension are agreed upon and further agreement is reached over whether intra-operative cardiac arrest will be treated or prolonged ventilation provided.38 In most cases in my experience, the patient or surrogate permits mechanical ventilation during and within a few hours of the surgical procedure but refuses consent for both intra-operative cardiac resuscitation and prolonged mechanical ventilation.

Although the DNR order was developed for inpatient use in hospitals and other institutions, there is no compelling reason for limiting it to them. Many patients want their DNR orders to remain in force during their outpatient care to prevent unwanted CPR by emergency medical service (EMS) personnel that otherwise would be required by their regulations if they determined that a patient needs CPR. As of 2006, at least 42 states had provided a legal mechanism for outpatient DNR orders that would be respected by EMS personnel called to treat them.39 Many states have created DNR wristbands, forms, or registries to identify valid outpatient DNR orders. In Oregon, Physician Orders for Life-Sustaining Treatment (POLST) now have become routine,40 noteworthy in a state in which an impressive 78% of decedents have written advance directives.41 In King County, Washington, a new guideline permits EMS personnel to withhold CPR from terminally ill patients if a family member or caregiver at the scene notifies them that the patient requested DNR status, even in the absence of a completed DNR form or bracelet.42



Withholding and Withdrawing Life-Sustaining Treatment in the Intensive Care Unit

Over the past century in the United States, there has been a striking change in how and where people die. Whereas, 100 years ago, most people died at home, now most people die in hospitals or nursing homes.43 And whereas formerly most people died of untreatable acute or chronic illnesses, today an increasing percentage of patients in hospitals die from refusal of LST. This phenomenon is particularly common in intensive care units (ICUs). Critically ill patients are admitted to ICUs with the hope of rescue therapy, but many do not recover. A large, recent epidemiologic study showed that as many as one in five Americans die in an ICU or shortly after they have received ICU care.44 Another recent population-based study showed that ICU admission rates strikingly increase with advancing age and the burden of coexisting chronic illnesses. The ICU admission rate is 75 times higher for patients over age 85 than for patients 18 to 44 years old and 900 times higher in persons with five or more chronic conditions than in those with none.45

Not only do many patients now die in ICUs but the mode of their demise is not entirely natural. Many or most ICU patients now die as a result of decisions made to limit treatment. In recent surveys, 40% to 65% of ICU deaths are the direct consequence of termination of LST resulting from patient or surrogate treatment refusals. Indeed, 74% of patients dying in ICUs have had at least some form of treatment withheld or withdrawn.46

The principles by which patients can refuse LST and the standards by which physicians must accede to these refusals have been asserted by a number of authorities over the past two decades.47 Physicians should explain the patient’s diagnosis and prognosis. Prognostic certainty often is impossible but the physician should make an evidence-based prognosis and communicate it with whatever confidence level is possible.48 The physician then should outline the acceptable treatment options and offer treatment alternatives that are medical and ethically appropriate, including maintaining or withdrawing LST. The physician should explain the concept of palliative care and that the patient will be made comfortable if LST is refused and withdrawn. The physician should offer a treatment recommendation based on the diagnosis, prognosis, and patient’s values and treatment goals, but the patient or surrogate has the authority to accept it or reject it.49

Despite this consensus, there remain cultural and geographic differences in the acceptance of these principles. A series of international conferences held at Appleton, Wisconsin between 1987 and 1991 developed a set of universally accepted principles for withholding and withdrawing LST, with only a few dissenters from the fifteen participating countries.50 Specific principles and practices of withholding and withdrawing LST reflecting national normative practices have been published from the Netherlands,51 Israel,52 Canada,53 and France.54

Three studies compared end-of-life practices in ICUs among European countries. The Ethicus Study of 37 ICUs in 17 European countries found that limiting LST in European countries was common but variable, and correlated with advancing age, severity of diagnoses, length of ICU stay, and geographic and religious factors.55 In another study of six European countries, the percentage of deaths preceded by end-of-life family decisions ranged from 23% in Italy to 51% in Switzerland.56 The European End-of-Life Consortium found great variation among countries, with Belgium, the Netherlands, and Switzerland forgoing treatment more often than Denmark, Italy, and Sweden.57

An essential ingredient in the discussion with the patient and surrogate is the identification of and agreement on the goals of medical treatment. In the case of an unequivocally dying patient, the goal may be purely palliation. When there is more than a trivial chance of saving the patient’s life, the goal may be both life-saving and palliation. When the prognosis is ambiguous, many patients and physicians agree on a time-limited trial of therapy. The patient consents to aggressive LST for an agreed-upon interval hoping for improvement. If improvement does not occur
by the end of this interval, the aggressive LST is discontinued and purely palliative care is provided.

A vexing situation arises when the critically ill ICU patient has lost decision-making capacity and there is neither family member nor surrogate decision maker on whom to rely for informed consent or refusal of LST. These patients who, in urban medical centers, often are homeless have been termed “unbefriended.”58 Douglas White and colleagues reported this circumstance in 16% of patients admitted to an ICU in San Francisco.59 They found that physicians generally based decisions to limit life support on their understanding of the patient’s diagnosis and prognosis and their determination of appropriate treatment. Notably, they requested neither further institutional nor judicial review in most cases. In a similar study of ICU deaths in seven medical centers, the same investigators found that 5.5% of cognitively incapacitated patients dying in the ICUs lacked both surrogate decision makers and advance directives.60 They observed a wide variability in physician practices and hospital policies about who was authorized to make decisions in such cases. Physicians managing such patients should follow their hospital’s decision-making policies.61

Holding a family conference is a common practice to maintain communication about treatment options and to solicit the family’s preferences for the treatment of critically ill patients.62 Families are told the diagnosis, prognosis with and without available treatments including palliative care, and their advice is sought to represent the patient’s wishes. These meetings often are productive but may yield conflict when family members disagree.63 Ethics consultants may help lead the meetings when conflict is anticipated.

Once patients or surrogates have made the decision to refuse LST, physicians should discuss with them exactly which treatments will be given and which will not. Following the principles of palliative care (chapter 7), I use a test I have found useful in such cases. If the treatment will contribute to the comfort of the patient, it will be provided; if not, it will be withdrawn or withheld. The goal of care in the setting of refusal of LST becomes to enhance the quality but not address the quantity of remaining life.

Once the decision has been agreed upon about the appropriate level of treatment, the physician should write explicit orders for medical and nursing care. These orders should be accompanied by explanations to the nursing staff that the orders follow the expressed wishes of the competent patient or of the incompetent patient as communicated by the surrogate. Most often the orders will be to limit the aggressiveness of LST. The exact language of any orders to limit therapy should make explicit which treatments will be provided and which will not. Some hospitals have developed specific treatment-limiting order pages with full palliative care orders.64

Physicians may enhance patients’ and families’ understanding by stratifying levels of treatment into descriptive classes that patients may accept or refuse. Level 1 is high-technology, high-expense, and high-invasiveness care, such as respirators, dialysis, cardiopulmonary resuscitation, and pacemakers. Level 2 is medications, such as vasopressors and antibiotics. Level 3 is hydration and nutrition. Level 4 is basic nursing care necessary to maintain hygiene, dignity, and comfort that should be maintained at all times.65

Studies of patients in intensive care units confirm that, in practice, the orders to limit treatment usually begin with omitting level 1, then encompass level 2, and finally include level 3. In an intensive care unit study of termination of LST, Smeidera and colleagues found that therapies were eliminated roughly in the following frequency and order: CPR, vasopressors, ventilators, supplemental oxygen, blood transfusions, antibiotics, antiarrhythymic drugs, dialysis, neurosurgery, intravenous fluids, and total parenteral nutrition.66

Physicians have personal biases that govern which therapies they are willing to discontinue and in what situations. One survey study found that physicians preferred to withdraw therapies: (1) from organs that failed from natural rather than iatrogenic causes; (2) that had been started recently, as opposed to those that had been of long duration; (3) that would
result in the patient’s immediate death rather than in delayed death; and (4) that would result in delayed death when the physician was unsure of the diagnosis.67

Deborah Cook and colleagues studied the factors associated with Canadian critical care physicians’ decisions to withdraw ventilation from critically ill ICU patients in anticipation of their death. They found that, more than severity of illness or degrees of organ dysfunction, the strongest predictors for withdrawal were: (1) physicians’ perceptions that patients would not want life support; (2) physicians’ predictions of low likelihood of survival irrespective of treatment; and (3) high likelihood of poor cognitive outcome.68

Steven Mayor and Sharon Kossoff reported their experience of withdrawal of LST in a neurological ICU. Brain-dead patients were excluded. Forty-three percent of dying patients were terminally extubated; the mean duration of survival following extubation was 7.5 hours. Morphine or fentanyl was administered to combat labored breathing in two-thirds. A subsequent survey of surrogate decision makers revealed that 88% were comfortable and satisfied with the process of withdrawing LST.69 Douglas White and colleagues showed that unfortunately, the ideal of shared decision making usually is not practiced in end-of-life decisions in ICUs, particularly among less educated families.70

Thomas Prendergast and Kathleen Puntillo reviewed families’ reasons to refuse to consider a physician’s recommendation to withdraw LST. They found four principal reasons: (1) mistrust of medical professionals resulting from lack of a prior relationship, perceived lack of empathy, or cultural or economic factors; (2) poor communication by medical personnel causing families to fail to understand the medical facts and clinicians’ reluctance to acknowledge dying; (3) guilt by family members over personal responsibility for the patient’s death or resulting from fractured past interpersonal relationships; and (4) families’ cultural, religious, or scientific views outside the mainstream such as considering withdrawal of LST as euthanasia or finding meaning in continuing non-cognitive life.71 Alexandre Lautrette and colleagues showed that implementing a proactive communication strategy with family members, including the use of specially designed brochures, lessened the burdens of subsequent bereavement.72

Physicians should strive to practice ideal palliative care (chapter 7) when withdrawing LST as outlined in detail by the Ethics Committee of the Society of Critical Care Medicine.73 The patient should be kept comfortable at all times through the judicious use of opiates, benzodiazepines, and barbiturates.74 Timothy Gilligan and Thomas Raffin showed that for the patient in whom the ventilator is being withdrawn, rapidly dialing down the ventilator settings was less uncomfortable for patients than extubation or prolonged terminal weaning.75 Reports from ICUs reveal that, in practice, nearly all non-comatose patients undergoing withdrawal of LST are given adequate doses of opiates and benzodiazepines, but there is no evidence that these medications when administered during ventilator weaning accelerate the moment of death.76 Some patients require continuous use of benzodiazepine and barbiturate sedation, a practice known as palliative sedation.77 Neuromuscular blocking drugs usually should be stopped.78

Several barriers impede the provision of ideal palliative care in the ICU. Many physicians continue to dichotomize therapeutic goals into curative and palliative. As long as the goal is curative, they may pay less attention to palliative issues. This phenomenon was shown clearly in the SUPPORT study (see below). In a survey of physician and nursing directors of 600 ICUs in the United States, Judith Nelson and colleagues identified several other barriers: (1) unrealistic family expectations causing unreasonable demands for more aggressive treatment; (2) the inability of most patients to participate directly in decision making about themselves; (3) lack of advance directives; (4) inadequate physician training in communication skills; (5) inadequate time for physicians to engage families in discussions; (6) inadequate space in the ICU for family meetings; and (7) lack of a palliative care service.79 Success in surmounting these barriers has formed the basis of defining quality indicators for end-of-life care in ICUs.80

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Aug 2, 2016 | Posted by in NEUROLOGY | Comments Off on Refusal of Life-Sustaining Treatment

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