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Extubation versus tracheostomy in withdrawal of treatment-ethical, clinical, and legal perspectives.
Chotirmall, Sanjay Haresh Flynn, Maura G Donegan, Ciaran F Smith, David O'Neill, Shane J McElvaney, Noel Gerard
Chotirmall, Sanjay Haresh
Flynn, Maura G
Donegan, Ciaran F
Smith, David
O'Neill, Shane J
McElvaney, Noel Gerard
Advisors
Editors
Other Contributors
Date
2010-06
Date Submitted
Keywords
Other Subjects
Subject Mesh
Adult
Beneficence
Critical Care
Decision Making
Great Britain
Humans
Hypoxia, Brain
Intubation, Intratracheal
Male
Personal Autonomy
Professional-Family Relations
Prognosis
Quality of Life
Tracheostomy
Value of Life
Withholding Treatment
Beneficence
Critical Care
Decision Making
Great Britain
Humans
Hypoxia, Brain
Intubation, Intratracheal
Male
Personal Autonomy
Professional-Family Relations
Prognosis
Quality of Life
Tracheostomy
Value of Life
Withholding Treatment
Planned Date
Start Date
Collaborators
Principal Investigators
Alternative Titles
Publisher
Abstract
The provision of life-sustaining ventilation, such as tracheostomy to critically ill patients, is commonly performed. However, the utilization of tracheostomy or extubation after a withdrawal of treatment decision is debated. There is a dearth of practical information available to aid clinical decision making because withdrawal of treatment is a challenging scenario for all concerned. This is further complicated by medicolegal and ethical considerations. Care of the "hopelessly ill" patient should be based on daily evaluation and comfort making it impossible to fit into general algorithms. Although respect for autonomy is important in healthcare, it is limited for patients in an unconscious state. Beneficence remains the basis for withdrawing treatment in futile cases and underpins the "doctrine of double effect." This article presents a relevant clinical case of hypoxic brain injury where a question of withdrawal of treatment arose and examines the ethical, clinical, and medicolegal considerations inherent in such cases, including beneficence, nonmaleficence, and the "sanctity of life doctrine." In addition, the considerations of prognosis for recovery, patient autonomy, patient quality of life, and patient family involvement, which are central to decision making, are addressed. The varying legal frameworks that exist internationally regarding treatment withdrawal are also described. Good ethics needs sound facts, and despite the lack of legal foundation in several countries, withdrawal of treatment remains practiced, and the principles described within this article aim to aid clinician decision making during such complex and multifaceted end-of-life decisions.
Language
en
ISSN
1557-8615
eISSN
ISBN
DOI
10.1016/j.jcrc.2009.08.007
PMID
19850443