1. Wittholding & withdarwing life support Done by Marah Derieh & Sojoud Omar

2. Introduction : The social commitment of the physician is to sustain life and relieve suffering. Where the performance of one duty conflicts with the other, the preferences of the patient should prevail. The principle of patient autonomy requires that physicians respect the decision to forego life-sustaining treatment of a patient who possesses decision-making capacity. Life-sustaining treatment is any treatment that serves to prolong life without reversing the underlying medical condition. Life-sustaining treatment may include, but is not limited to, mechanical ventilation, renal dialysis, chemotherapy, antibiotics, and artificial nutrition and hydration.

3. When to remove mechanical ventilator When a permanently unconscious patient was never competent or had not left any evidence of previous preferences or values, since there is no objective way to ascertain the best interests of the patient, the surrogate’s decision should not be challenged as long as the decision is based on the decision maker’s true concern for what would be best for the patient. Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care. This includes providing effective palliative treatment even though it may hasten death.

4. Even if the patient is not terminally ill or permanently unconscious, it is not unethical to discontinue all means of life-sustaining medical treatment in accordance with a proper substituted judgment or best interests analysis.

5. Nurses role Three Nursing Roles 1. The nurse as a skilled clinician. 2. The nurse as an advocate. 3. The nurse as a guide.

6. 1. Skilled Clinician: This refers to the assessment and technical skills needed to manage care for someone at the end of his or her life. The nurse must have the clinical skills to care for the pt, to know how to assess her/his pain, how to use other health care team members as resources, and how to intervene to keep her/him comfortable. 2.Advocate: This refers to the work a nurse needs to do to obtain the best care for a patient. To have advocacy skills, to have insisted on better pain relief from the pt’s doctor. To worke on ensuring social work availability for pt’s family and clear systems for reaching a nurse on call.

7. 3. Guide: This refers to the knowledge, communication, and intuition a nurse needs in order to walk with a patient during that difficult last journey. The nurse must be a skilled guide for pt, to be able to prepare her/him for death, to be able to help her/his family with simple assurances.

8. Summary The clinician’s responsibility to the patient does not end with a decision to limit medical treatment, but continues through the dying process. Every effort should be made to ensure that withdrawing life support occurs with the same quality and attention to detail as is routinely provided when life support is initiated. Approaching the withdrawal of life support as a medical procedure provides clinicians with a recognizable framework for their actions. Key steps in this process are identifying and communicating explicit shared goals for the process. Our hope is that adopting a more formal approach to this common procedure will improve the care of patients dying in intensive care units.

9. Pt refuse treatment : There are the circumstances under which patients may make a decision not to be treated. If you are trying to make a refusal decision yourself Call on a professional shared decision making expert to help you make this difficult decision. The shared decision making process helps you weigh your values and beliefs against your options to make the choice that is best for you.shared decision making expert

10. * Non-Life-Threatening Treatment Decisions : Most patients in the United States have a right to refuse care if the treatment is being recommended for a non-life- threatening illness. You have probably made this choice without even realizing it. Maybe you didn't fill a prescription, chose not to get a flu shot or decided to stop using crutches after you sprained an ankle. You may also be tempted to refuse a treatment for more emotional reasons. Perhaps you know it will be painful or you are afraid of the side effects. There is nothing illegal about choosing to forgo treatment for any of those reasons. They are personal choices, even if they aren't always wise choices. However, there are some patients who do not have the legal ability to say no to treatment. Most of these pt cannot refuse teartment even if it is non-life threatening.

11. * End-of-Life-Care Refusal : Choosing to refuse treatment at the end of life addresses life-extending or lifesaving treatment. The right to refuse end-of-life care was guaranteed to Americans in 1991 with the passage of the federal Patient Self- Determination Act (PSDA). The PSDA mandated that nursing homes, home-health agencies and HMOs were required by federal law to provide patients with information regarding advance directives, including DNRs (do not resuscitate), living wills and other discussions and documents. It also guaranteed that Americans could choose to refuse life-sustaining treatment at the end of life.advance directives When we choose not to be treated, knowing that the refusal will shorten our lives, it is usually because we are choosing what we believe will be a better quality of life, rather than a longer life that may be less pleasant. Some people, knowing they are going to die soon, even choose to end their own life rather than be faced with decisions that will, in reality, be executed by others. Be aware that if you choose not to receive life-sustaining treatment, it does not mean you are required to forfeit palliative care, which can be administered even for patients who do not want to be kept alive.Palliative care focuses on relieving pain at the end of life, but does not help extend life.Palliative care Before you decide against receiving treatment at the end of your life, be sure you've followed steps to help you to make that informed decision.followed steps to help you to make that informed decision

12. * Using Religion to Refuse Treatment : Followers of two Christian religions - Jehovah's Witnesses and Christian Scientists - plus a few other non-affiliated churches in different parts of the United States - may be willing to undergo some forms of treatment, but restrict or deny other forms based on their religious beliefs. Each offers clear guidelines for making that determination. Adults may rely on their church affiliation and its tenets to refuse treatment for themselves if they choose. However, they have less legal standing when it comes to making those choices for their children. Several court cases regarding children with different diseases and medical needs have addressed the legality of refusing treatment based on religious reasons, with varying outcomes.