Ethics

Withholding or Withdrawing Life-Sustaining Treatment

Code of Medical Ethics Opinion 5.3

Decisions to withhold or withdraw life-sustaining interventions can be ethically and emotionally challenging to all involved. However, a patient who has decision-making capacity appropriate to the decision at hand has the right to decline any medical intervention or ask that an intervention be stopped, even when that decision is expected to lead to his or her death and regardless of whether or not the individual is terminally ill. When a patient lacks appropriate capacity, the patient’s surrogate may decline an intervention or ask that an intervention be stopped in keeping with ethics guidance for surrogate decision making.

While there may be an emotional difference between not initiating an intervention at all and discontinuing it later in the course of care, there is no ethical difference between withholding and withdrawing treatment. When an intervention no longer helps to achieve the patient’s goals for care or desired quality of life, it is ethically appropriate for physicians to withdraw it.

Physicians should elicit patient goals of care and preferences regarding life-sustaining interventions early in the course of care, including the patient’s surrogate in that discussion whenever possible. When facing decisions about withholding or withdrawing life- sustaining treatment the physician should:

(a) Review with the patient the individual’s advance directive, if there is one. Otherwise, elicit the patient’s values, goals for care, and treatment preferences. Include the patient’s surrogate in the conversation if possible, even when the patient retains decision-making capacity.

(b) Document the patient’s preferences and identify the patient’s surrogate in the medical record and ensure that the record includes the patient’s written advance directive or durable power of attorney for health care (DPAHC), where applicable.

(c) Support the decision-making process by providing all relevant medical information to the patient and/or surrogate.

(d) Discuss with the patient and/or surrogate the option of initiating an intervention with the intention of evaluating its clinical effectiveness after a given amount of time to determine if it has led to improvement. Confirm that if the intervention has not achieved agreed-on goals, it may be withdrawn.

(e) Reassure the patient and/or surrogate that all other medically appropriate care will be provided, including aggressive palliative care, appropriate symptom management if that is what the patient wishes.

(f) Explain that the surrogate should make decisions to withhold or withdraw life-sustaining interventions when the patient lacks decision-making capacity and there is a surrogate available and willing to make decisions on the patient’s behalf, in keeping with ethics guidance for substituted judgment or best interests as appropriate.

(g) Seek consultation through an ethics committee or other appropriate resource in keeping with ethics guidance when:

  1. The patient or surrogate and the health care team cannot reach agreement about a decision to withhold or withdraw life-sustaining treatment.
  2. There is no surrogate available and willing to make decisions on behalf of a patient who does not have decision-making capacity or no surrogate can be identified.
  3. In the physician’s best professional judgment a decision by the patient’s surrogate clearly violates the patient’s previously expressed values, goals for care, or treatment preferences, or is not in the patient’s medical interest.

(h) Ensure that relevant standards for good clinical practice and palliative care are followed when implementing any decision to withdraw a life-sustaining intervention.

AMA Principles of Medical Ethics: I, III, IV, V

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Code of Medical Ethics: Caring for Patients at the End of Life

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