Deciding Alone: Unilateral Withdrawal of Life-Sustaining Interventions

Introduction

The bioethics grand round, presented by the Center for Medical Ethics and Health Policy at Baylor College of Medicine, featured a debate on the ethical considerations surrounding the unilateral withdrawal of life-sustaining interventions, focusing particularly on ECMO (extracorporeal membrane oxygenation). The discussion included perspectives from bioethicists and clinicians. A central case involved Mr. J, a 45-year-old ICU patient with severe respiratory failure post-COVID-19, who was sustained on ECMO for over 60 days. Although initially considered for a lung transplant, he was later declined due to high sensitization with anti-HLA antibodies and could not be weaned off ECMO. Despite a poor prognosis, Mr. J was sometimes awake and oriented, expressing his wish to continue ECMO, supported by his wife. This scenario raised the ethical dilemma of whether to continue ECMO support when it is deemed medically inappropriate, described as a "bridge to nowhere".

Arguments For Unilateral Withdrawal

• Medical Appropriateness and Obligation: Dr. Fedson argued that unilateral withdrawal of inappropriate care is not only ethical but an obligation for medical professionals. Medical judgment remains crucial, and interventions that are ineffectual or potentially harmful are not obligatory.
• Shared Decision-Making: Shared decision-making balances patient autonomy with medical judgment, emphasizing the principle of primum non nocere (do no harm). Interventions should be medically reasonable, and healthcare providers should aim to maximize benefit while minimizing harm.
• Futility Concepts:
  • Physiologic Futility: Interventions that cannot achieve their intended physiological outcome are considered futile.
  • Clinical Futility: Treatment that does not alter the medical course of the disease.
  • Inappropriate Treatment: Interventions lacking a reasonable expectation of patient survival outside acute care or the ability to perceive benefits.
• ECMO as a Short-Term Bridge: ECMO is designed as a short-term device to bridge patients to recovery, another therapy, or transplant. In Mr. J's case, ECMO would not be indicated because he is neither a transplant candidate nor expected to recover.
• Resource Allocation: Continuing ECMO when medically inappropriate limits care for other patients due to the intensive resources required, including ICU beds, nursing staff, and blood products.
• Professional Obligations: Medical professionals have an ethical duty to provide appropriate care and avoid offering interventions that are not indicated.

Arguments Against Unilateral Withdrawal

• Importance of Patient Preference: Dr. Smolenski contended that medical inappropriateness depends on a patient's self-reported acceptable quality of life.
• Qualitative Futility: An intervention is not qualitatively futile if the patient can appreciate its effects as beneficial, emphasizing the patient's perspective on what constitutes a benefit.
• Moral Difference Between Withdrawal and Withholding: Withdrawing a treatment, once initiated, involves additional harm to a patient who is alert and oriented, violating their reasonable expectation of continued care.
• Scarcity Considerations: While scarcity raises concerns about resource allocation, it should not dictate individual treatment decisions for patients with established caregiving relationships. Decisions should be based on medical inappropriateness, not driven by resource limitations.
• Patient's Perspective: Awake and oriented patients on ECMO may still experience meaningful activities and derive quality of life, which should be respected.

Clinical Perspectives

• Patient Advocacy: Mary Moubark, an ICU nurse, emphasized the importance of listening to patients and advocating for their wishes. The complications associated with ECMO, such as circuit clots and bleeding, along with the emotional toll on patients and caregivers, were highlighted.
• Multidisciplinary Support: Utilizing resources like music and art therapy can provide guidance and support for patients and families.
• Challenges and Fears: Subhasis Chatterjee, M.D., a cardiovascular surgeon and intensivist, noted that the biggest challenges often involve family relationships when patients are minimally conscious. Clinicians may hesitate to unilaterally withdraw care due to fear of litigation, despite legal protections like the Texas Advance Directives Act (TADA).
• Epistemic Authority and Humility: Recognizing the limits of medical expertise and remaining open to new possibilities, as demonstrated during the COVID-19 pandemic, is crucial. Cultural and religious beliefs also significantly influence end-of-life decisions.
• Importance of Early and Honest Discussions: Early and honest discussions with patients and families are essential for navigating these complex decisions.

Discussion and Questions

• Assessing Quality of Life: When patient preferences are unknown, surrogates and family members who know the patient best should be consulted.
• The Role of Consciousness: The ability of the patient to perceive benefits is crucial; patients in a coma are unable to appreciate the benefits of therapy.
• ECMO Availability: If ECMO were ubiquitously available and inexpensive, its perception might shift from a "bridge to nowhere" to a more routine intervention, similar to pacemakers or dialysis. However, the intensive care and resources required, along with the invasive nature and risks of ECMO, would still necessitate careful consideration.
• Mobile ECMO: While mobile ECMO units exist, particularly for rapid deployment, maintaining chronic ECMO patients in non-ICU settings faces technological and logistical challenges.

Conclusion

The debate highlighted the complex ethical considerations surrounding the unilateral withdrawal of life-sustaining interventions such as ECMO. Differing views on medical appropriateness, patient autonomy, resource allocation, and the moral distinctions between withholding and withdrawing treatment were presented. The clinical perspectives underscored the importance of patient-centered care, the challenges faced by healthcare providers, and the need for open communication and multidisciplinary support in these difficult situations.

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