Caring for patients at the end of life can be intimidating for RTs who have never had to make decisions about discontinuing life support, but being armed with good information and practicing good ethics will ensure they make the right decisions.

Encounter issues involving end-of-life ethics in their roles as health care professionals. While some RTs face these decisions more often than others may, it is part of the job to treat patients, support patients and families emotionally, and collaborate with physicians and nurses while end-of-life decisions are made. An important thing to remember in such situations is that lack of information can be a problem, but misinformation can be devastating. It is necessary to avoid several myths1 that can arise during end-of-life care in order to apply clinical ethics properly to end-of-life decisions.

Ethical Decision-Making
Much effort goes into making appropriate clinical decisions on what to do, when to do it, and how long to do it. Ethical decision-making itself is a broad topic, but it has four basic components2:

•    the medical picture,
•    the patient’s goals and preferences,
•    the daily-life picture and quality of life, and
•    contextual factors.

In the medical picture, the patient’s diagnosis and prognosis are the first considerations. It is vital to explore and then articulate the achievable medical goals, given the patient’s pathology and chance of recovery. From that point, one can move to consideration, without personal or financial bias, of all available, reasonable options. In explaining the possible benefits, risks, and burdens of treatment options, the responsible physician should offer a recommendation based on medical objectives and known patient goals.

Determining an incapable patient’s goals and preferences may be difficult, but the effort is vital to charting a beneficial course of treatment for the patient. Assessing the patient’s decisional capacity, reviewing any advance directives, and identifying surrogate decision-makers are keys to establishing pertinent patient goals and preferences. When these are not known through advance directives or the information provided by family members and friends, decisions should be based on the patient’s medical best interests (defined as what a reasonable person would want, under the circumstances).

To understand what the course of treatment should be, it is important to have an overall understanding of the patient’s daily life. Where do pain and suffering fit into any benefit-to-burden ratio? What are the patient’s daily activities, and does the prognosis allow for continuing those activities, either as they are or after modifications to make them easier? How is the patient expected to react to changes in his or her life? Will the patient’s ability to function or social relationships be significantly affected? Will treatment require the patient’s removal from a cherished social circle? What are the patient’s main sources of enjoyment, and what (if any) effects will the recommended course of therapy have on them?

Each person creates goals and values based on what is important to the individual. Having the health care team understand what quality of life means to the individual is important to the creation of a clinical plan of action.

In addition to the patient, there are others whose interests may be involved. The needs of family caregivers should be addressed. If the patient will need hemodialysis, for example, and there are financial or transportation challenges involved, what resources are available? Cultural and ethnic values also may come into play when a person is ill or disabled. Should the patient’s spiritual/religious beliefs influence the decision? Is the patient’s faith community available for support? In addition, the range of options for treatment may be narrowed or expanded by the patient’s health care insurance (or lack thereof), by institutional policies, and by available outpatient care settings. At times, treatment options are limited by the policies of a hospital affiliated with a religious organization.

A Sample Methodology
Ethical problems sometimes arise rather quickly, leaving the RT faced with some decision-making challenges. Although immediate ethics intervention is not seen as often in critical care as it is in the emergency department, it may be helpful to adopt some steps common to both environments. A three-step process can guide an RT through clinical situations having an ethical background.3 The RT should first ask whether the current situation represents a type of ethics problem for which a rule has already been worked out, or to which a rule designed for a similar situation can be extended. If so, the rule should be followed.

If no rule is applicable at present, is there an option that will buy time for deliberation without excessive risk to the patient? If so, that option should be applied. A decision not to decide is the right decision at times. If it is possible to care for the patient for a period of time without risk as the team deliberates, then that course should be followed by all means. It is better to take a considered course of action later than to do something merely for the sake of doing something immediately.

If the first two steps yield no solution, the principles of impartiality, universality, and interpersonal justification should be applied to the situation. To apply the principle of impartiality, one should ask whether one would be willing, in the patient’s place, to have this action performed. Universality applies if one would be willing to have the same solution used in all similar cases. If not, one should hesitate; it is hard to defend the notion there is ethical justification for the solution in this case alone. Interpersonal justification is applied by asking oneself how this choice would be defended to peers, superiors, and the public.

Summary
End-of-life decision-making at the bedside does not have to be intimidating to the RT. Sometimes, simply asking what is being done and what is known about the patient’s wishes can activate critical, patient-centered thinking. In many cases, the RT with a knowledge of ethics can become a valuable resource for the patient and for colleagues on the health care team.

Debunking the Myths

Myth 1: Anything that is not specifically allowed by law is prohibited. This is false, since many decisions not addressed by legislation or court decisions are made at the bedside in hospitals every day. Laws pertaining to the use of life support and surrogate decision-making provide general guidelines, but do not attempt to micromanage individual situations. Many appellate-court cases regarding discontinuation of life support heard since the 1970s have been filed by individuals seeking to discontinue treatment, not to extend it.

Myth 2: Termination of life support is murder or suicide. In reality, both murder and suicide are thought of as intentionally, actively, and artificially inducing death. This is completely different from allowing death to occur as a result of natural causes when further medical treatment cannot restore life. To discontinue a death-delaying intervention is not to cause death, but is to allow an inevitable death to occur.

Myth 3: A patient must be terminally ill for life support to be stopped. One of the basic tenets of clinical ethics is, instead, that each patient has the right of self-determination. This right is not activated on the verge of death alone. An otherwise healthy hemorrhage patient who is capable of making decisions might, for example, be likely to survive if given two units of blood. Nonetheless, this patient may decline the transfusion, even if the outcome will be the patient’s death. Likewise, a patient with nonterminal chronic obstructive pulmonary disease may elect to have mechanical ventilation stopped, even when this would certainly result in death. While there are exceptions (as for physically healthy but actively suicidal patients), and while precautions must be taken if the surrogate decision-makers of an incapacitated patient are unknown or in conflict, capable patients have the right to accept or decline any or all recommended medical treatments, including life-sustaining treatments.

Myth 4: It is permissible to terminate extraordinary measures, but not ordinary ones. This is untrue because treatment is treatment, regardless of its complexity or invasiveness. If a ventilator-dependent patient’s ventilator is to be removed, what is the purpose of continuing to provide vasopressors, antibiotics, or intravenous fluids? Treatments should be assessed not according to the technology involved, but based on the benefit to the patient versus the burden of the intervention. When a treatment becomes merely death delaying and offers a burdensome or unacceptable quality of existence (from the patient’s perspective), its goal should be clearly stated and justified. One goal that is always achievable, however, is the alleviation of suffering. Pain relief, symptom management, and comfort are necessary measures owed to the patient.

Myth 5: It is permissible to withhold treatment, but it must be continued if started. If this were true, increased lengths of stay would drive US hospitals out of business. One may start a treatment, evaluate the results in terms of both medical effectiveness and acceptable quality of life, and then adjust or discontinue it (based on the patient’s preferences, the likelihood of medical benefit, and the impact of continuing treatment on the patient’s quality of life). The trial of a given therapy provides patients or their surrogates with valuable data for deciding whether to continue treatment. Continuing nonbeneficial therapy just because it was started makes no sense.

Myth 6: :Stopping tube feeding differs legally from stopping other treatments. Although statutes vary from state to state, artificial nutrition and hydration therapy (tube feeding) is life-sustaining treatment installed and maintained by trained professionals. It is a clinical intervention based on specific indications and contraindications; it should be offered on the basis of published data indicating likely benefits, mortality, and morbidity risks (best practices); and it can be initiated, continued, or discontinued based on informed consent by the patient or surrogate and assessment of burden versus benefit.

Myth 7: Terminating life support requires going to court. In reality, treatment may be discontinued when it is unwanted by a capable patient (or authorized surrogate) or when it has become nonbeneficial. Court cases involving the discontinuation of life support usually arise from disputes within the health care team, among the family members or surrogates, or between the health care team and the family.

Myth 8: Advance directives are not legal. Advance directives such as the power of attorney for health care, the living will, the prehospital do-not-resuscitate order, and the advance health care directive embody the competent patient’s right to self-determination and express this consensus in federal and state law: the patient’s right to direct health care does not evaporate when the patient loses the ability to make health care decisions. Advance directives are legally binding in all states, and all states recognize the validity of legal advance directives from other states.

Dave Walsh, RRT, RCP, is president, DRW & Associates, Chicago. Daniel O. Dugan, PhD, is health care ethics consultant at Swedish Covenant Hospitl, Chicago, and at Emmanual Medical Center, Turlock, Calif.

References
1. Meisel A. Legal myths about terminating life support. Arch Intern Med. 1991;151:1497-1502.
2. University of Washington School of Medicine. Ethics in medicine. Available at: http://eduserv.hscer.washington.edu/bioethics/tools/cesumm.html.   Accessed January 4, 2006.
3. Iserson KV. Emergency medicine and bioethics: a plan for an expanded view. J Emerg Med. 1991;9suppl:65-6. Available at: www.samct.co.ar/revi2002/rev4/trab15.pd.