WITHDRAWAL OF THERAPY By J.A.AL-ATA CONSULTANT & ASSISTANT PROFESSOR OF PEDIATRIC CARDIOLOGY CHAIRMAN, BIO-ETHICS COMMITTEE KFSH-RC JED.

DEFINITION  Withdrawal of advanced life support (e.g. mechanical ventilation) when continued ICU care becomes futile or when brain death is established.  However, a narrow definition of futility in this situation is the key, since the concept of futility could lead to inappropriate decisions.  It is best to consider a situation futile when the patient is terminally ill, the condition is irreversible, and death is imminent.

IMPORTANT POINTS  The patient is always the key source of authority in these decisions.

CONT;  The most important ingredient in end-of-life decision making is effective communication.

CONT;  It is important to try to ascertain what the patient thought about quality-of-life values before surrogate decisions can be made on the patient's behalf.

CONT;  The concepts of : beneficence, nonmaleficence, autonomy, and justice are the foundation of ethical decision making.  Treatment is not mandatory.

IMPLICATIONS OF AUTONOMY  Competent ( MENTAL, AGE, AUTONOMY, INFORMED ) patients have the right to refuse treatment  Patient guardian does not have the right to refuse treatment in non-futile situation in which refusal of treatment will significantly harm the patient.

CONT;  Studies showed poor agreement between patients and surrogates suggesting that substituted judgment is not an accurate tool to make end-of- life decisions.  Islamically and probably in other faiths a patient is encouraged to seek and accept treatment leading to cure or substantial improvement or preventing significant harm.

THE WITHDRAWAL PROCESS  Establishing the futile situation and/ or brain death.

BRAIN DEATH CRIETERIA  Deep coma with cessation of respiration.  Irreversible diagnosed brain or brain stem injury for which there is no cure or palliation.  No cause for transient coma (e.g. hypoglycemia or hypothermia or sedative drugs----etc.  Evidence of no brain stem function  Enough time  Confirmatory tests

CONT;  OR, a confirmed futile state judged at least by two consultant physicians.

CONT;  Proper communication between treating physicians, nursing, bio-ethics to gather information about the medical,social,religious & cultural,emotional, and legal situation.

CONT;  Meeting the concerned family members or guardians:  Showing empathy,concern.  Aiming at explaining the state till well understood & at reaching a gradual thoughtful decision with them.  Give NEEDED time  Act truly as the patient and family advocate.

CONT;  If the decision is made, document in the chart and implement in a timely manner.  If there is opposition allow time for reconsideration.  explore your alternatives  Avoid confrontation and do not wave with legislative empowerment you have early.

CONT;  Support the family and attend to their wishes and needs  Direct them (if ok) to spend more time with the patient and attend to his or her non-medical current needs  Involve the Imam or chaplan

CONT;  Better to wean from the vent. rapidly than to stop it at once  Comfort,comfort,  NO pain (avoid over sedation)  Oxygen  Hydration  Maintaining blood glucose not necessarily nutrition  Quiet, private environment.

CONT;  DON ’ T FALL IN THE TRAP OF EUTHANASIA, ASSISTED SUICIDE  MODIFY PLANS AS CHANGES COME.

TIPS TO SUCCESSFUL THERAPY WITHDRAWAL  Discuss issues early with the patient and get to his or her wishes.  Have good rapport with patient and family.  Evaluate your patient properly before embarking on a heroic management plan.

Situations in which CPR should be performed:  People likely to benefit from CPR should be given this treatment if the need arises, unless they have specifically rejected it.  People for whom the benefit of CPR is uncertain or unlikely should be given this treatment if the need arises, unless they have specifically rejected it. CPR should be initiated until the patient's condition has been assessed.

Situations in which CPR should not be performed:  People who have rejected CPR and those who almost certainly will not benefit from it should not be given this treatment if an arrest occurs.

Review of CPR decisions  In the following circumstances review of decisions should be undertaken immediately: 1. If a competent person (or proxy) changes his or her decision about resuscitation. 2. If there is a significant, unexpected change in a person's condition.

CONT;  A decision not to initiate CPR does not imply the withholding or withdrawing of any other treatment or intervention.  A person who does not receive CPR should receive all other appropriate treatments, including palliative care, for his or her physical, mental and spiritual comfort.

THANK YOU