ON THE LIMITATION OF LIFE-SUSTAINING THERAPY
1. The Hong Kong College of Anaesthesiologists (HKCA) recognizes that the uncritical application of medical technology in the Intensive Care Unit can cause excessive suffering for patients and their families with little or no benefit. The withdrawing or withholding of life sustaining therapy may be appropriate in some circumstances.
2. Definitions: Life sustaining therapy can be defined as any treatment intended to correct life-threatening infection, haemodynamic instability, poor tissue oxygenation, or biochemical or haematological derangements. This includes ventilation, inotropes, antibiotics, antiarrhythmics, renal replacement therapy, nutrition, blood or blood products, intravenous fluids, or any other supportive therapy. Withdrawal of life sustaining therapy can be defined as the cessation or removal of established life-sustaining therapy including vasopressors, oxygen, mechanical ventilation or renal replacement therapy. Withholding of life sustaining therapy can be defined as where a new or existing medical therapy thought to be necessary for continued life support is not started or escalated, respectively. Withholding of resuscitation can be defined as where continuation of appropriate medical treatment to the point at which death is considered inevitable is followed by a decision not to initiate cardiopulmonary resuscitation.
3. In intensive care, the potential benefits of treatment are prolongation of life and/or avoidance of disability. These must be weighed against the potential costs of pain and suffering (of both patient and family), loss of dignity, and the social justice of equitable access to treatment. Current knowledge allows only probability rather than certainty of prognosis. HKCA endorses the fundamental principle of respect for human life including the ethical principles of patient autonomy, distributive justice, beneficence and non-maleficence in the provision of medical care but recognizes that these principles are often in conflict and that balancing them depends on the philosophical viewpoint used.
4. It is appropriate to limit life sustaining therapy that is physiologically futile or ineffective. In other circumstances, consideration of the withholding or withdrawing of life sustaining therapy should take into account the following factors: the opinion of the patient (if competent) or the next-of-kin's understanding of the patient's wishes with regard to an acceptable quality of life and acceptable burden of treatment and the nature and probability of potential outcomes.
5. Consideration of withdrawal or withholding of life sustaining therapy may be sought by the patient, the next-of-kin, or the medical or nursing staff. The HKCA endorses that all health care decisions including decisions to withhold or withdraw life sustaining therapy should be based on the best available evidence. Any decision to withdraw or withhold life sustaining therapy should be taken following consensus among the intensive care team and with the primary referral team. Dissent should be resolved over time by discussion.
6. Following medical consensus, the next-of-kin should be approached for their concurrence to the implementation of the medical decision. This process should not be rushed and may require some time. The factors taken into account in reaching this decision should be explained and it should be made clear that the ultimate burden of end-of-life decision making for an incompetent patient rests with the medical team. In rare cases when there is persistent disagreement between the health care team and the next-of-kin, consideration may be given to involving non-medical professionals, clinical ethics committees, or the courts.
7. When withdrawal or with holding of life sustaining therapy occurs and death is inevitable and proximate, an alternative care plan ('comfort care') should be implemented with its focus on the relief of the pain, discomfort and distress of the patient and the family. HKCA endorses the use of medication for patient symptom control in this setting, even though this may foreshorten life.
versus withdrawing treatment.
Although ethicists commonly hold the view that withholding treatment and
withdrawing treatment are ethically the same, there are a number of practical
differences. Withholding treatment
assumes that a patient's outcome will be the same as a group of similar
patients, whereas withdrawal of treatment is with the knowledge of that
patient's actual response to treatment. Decisions to withhold
treatment should be taken with the same level of certainty of outcome as
decisions to withdraw treatment.
defined as “the direct intentional killing of a patient as part of the medical
care being offered”. HKCA does not support this practice.
The withdrawal or withholding of life-sustaining therapy is not
In preparing the Statement reference was made to other
similar statements including
Council of Hong Kong Professional Code and Conduct (2000) for the Guidance of
Registered Medical Practitioners.
Statement of the Hospital Authority guidelines (2002) on life-sustaining
treatment in the terminally ill.
Statement of the Australian and New Zealand Intensive Care Society (2001) on
withholding and withdrawing treatment.
Medical Association Guideline (1999). Withholding and withdrawing
life-prolonging medical treatment. Guidance for decision making.
This Statement has been prepared by the Intensive Care
Committee of the Hong Kong College of Anaesthesiologists and was endorsed at the
College Council Meeting held on the 9th January, 2002.