Deciding Alone: Unilateral Withdrawal of Life-Sustaining Interventions
* You will be redirected to the BCM DCPD credit management site when claiming credit and may be asked to register or log in.
In this presentation, speakers Dr. Subhasis Chatterjee, Dr. Savitri Fedson, Mary Moubark, B.S.N., R.N., C.C.R.N., and Dr. Joanna Smolenski discuss life-sustaining interventions, such as ECMO, and the ethical considerations of their use in the context of medically appropriate treatment and withdrawal of care. The group discussion also contemplates medically ethical actions surrounding these complex situations.
This Bioethics Grand Rounds session took place on Wednesday, September 11, 2024 at 5:00 p.m. and has been approved for CME, Ethics, and Social Work Credit.
Activity Information
How to Claim Credit
You may claim credit after watching this activity.
You will be redirected to the BCM DCPD credit management site when claiming credit and may be asked to register or log in.
Needs Statement
Ethical dilemmas can arise in the day-to-day practice of physicians, nurses, social workers, advanced practice providers, and other allied health professionals. The series aims to review classic and emerging issues in healthcare, focusing on developments in the field of clinical ethics, the practice of ethics consultation, and the role of ethics in shared clinical decision-making. The series also aims to expand the knowledge of learners, foster the skills needed to resolve ethical dilemmas in clinical practice, and enhance the quality of patient care.
Educational Objectives
At the conclusion of the activity, the participants should be able to:
- Describe circumstances in which life-sustaining interventions may be considered potentially inappropriate treatment.
- Identify ethical arguments for and against unilateral withdrawal of life-sustaining interventions when they are no longer a bridge to a destination therapy.
- Recognize the challenges of caring for patients dependent on life-sustaining interventions such as extracorporeal membrane oxygenation (ECMO).
Target Audience
Professional Categories
- Physicians
- Medical Students
- Fellows
- Residents
- Nurses
- Other Health Professionals
Specialties
- Internal Medicine
Interest Groups
- Ethics
- Hospital Medicine
Activity Evaluation
Evaluation by questionnaire will address program content, presentation, and possible bias.
Educational Methods
- Lectures
Accreditation/Credit Designation
Baylor College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Baylor College of Medicine designates this enduring activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This activity has been designated by Baylor College of Medicine for 1.0 credit of education in medical ethics and/or professional responsibility.
Social Work: The Baylor College of Medicine Division of Continuing Professional Development (License Number 7270) is an approved continuing education provider for Social Workers through the Texas State Board of Social Worker Examiners. This activity has been approved for 1 continuing education unit.
Activity Directors
Moderator
Term of Approval
November 1, 2024 through November 30, 2026. Original release date: November 1, 2024.
Disclosure Policy
Baylor College of Medicine (BCM) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education (CME) for physicians. BCM is committed to sponsoring CE activities that are scientifically based, accurate, current, and objectively presented.
In accordance with the ACCME Standards for Commercial Support, BCM has implemented a mechanism requiring everyone in a position to control the content of an educational activity (i.e., directors, planning committee members, faculty) to disclose any relevant financial relationships with commercial interests (drug/device companies) and manage/resolve any conflicts of interest prior to the activity. Individuals must disclose to participants the existence or non-existence of financial relationships at the time of the activity or within 24 months prior.
In addition, BCM has requested activity faculty/presenters to disclose to participants any unlabeled use or investigational use of pharmaceutical/device products; to use scientific or generic names (not trade names) in referring to products; and, if necessary to use a trade name, to use the names of similar products or those within a class. Faculty/presenters have also been requested to adhere to the ACCME's validation of clinical content statements.
BCM does not view the existence of financial relationships with commercial interests as implying bias or decreasing the value of a presentation. It is up to participants to determine whether the relationships influence the activity faculty with regard to exposition or conclusions. If at any time during this activity you feel that there has been commercial/promotional bias, notify the Activity Director or Activity Coordinator. Please answer the questions about balance and objectivity in the activity evaluation candidly.
All of the relevant financial relationships listed for these individuals have been mitigated.
Bartlett RH, Ogino MT, Brodie D, et al. Initial ELSO Guidance Document: ECMO for COVID-19 Patients with Severe Cardiopulmonary Failure [published correction appears in ASAIO J. 2020 Aug;66(8):e113. doi: 10.1097/MAT.0000000000001219]. ASAIO J. 2020;66(5):472-474. doi:10.1097/MAT.0000000000001173.
Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. The Journal of Heart and Lung Transplantation. 2023;42(12):1770. doi:10.1016/j.healun.2023.10.018.
Bosslet GT, Pope TM, Rubenfeld GD, et al. An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Respir Crit Care Med. 2015;191(11):1318-1330. doi:10.1164/rccm.201505-0924ST.
Brody BA, Halevy A. Is futility a futile concept? Journal of Medicine and Philosophy. 1995;20(2):123-144. doi:10.1093/jmp/20.2.123.
Childress A, Bibler T, Moore B, et al. From Bridge to Destination? Ethical Considerations Related to Withdrawal of ECMO Support over the Objections of Capacitated Patients. Am J Bioeth. 2023;23(6):5-17. doi:10.1080/15265161.2022.2075959.
Dunlay SM, Strand JJ, Wordingham SE, Stulak JM, Luckhardt AJ, Swetz KM. Dying With a Left Ventricular Assist Device as Destination Therapy. Circ Heart Fail. 2016;9(10):e003096. doi:10.1161/CIRCHEARTFAILURE.116.003096.
Elwyn G, Frosch D, Rollnick S. Dual equipoise shared decision making: definitions for decision and behaviour support interventions. Implement Sci. 2009;4:75. Published 2009 Nov 18. doi:10.1186/1748-5908-4-75.
Griener GG. The physician’s authority to withhold futile treatment. Journal of Medicine and Philosophy. 1995;20(2):207-224. doi:10.1093/jmp/20.2.207.
Guglin M, Zucker MJ, Bazan VM, et al. Venoarterial ECMO for Adults: JACC Scientific Expert Panel. J Am Coll Cardiol. 2019;73(6):698-716. doi:10.1016/j.jacc.2018.11.038.
Jansen LA. Hastening death and the boundaries of the self. Bioethics. 2006;20(2):105-111. doi:10.1111/j.1467-8519.2006.00481.x.
Kruser JM, Taylor LJ, Campbell TC, et al. "Best Case/Worst Case": Training Surgeons to Use a Novel Communication Tool for High-Risk Acute Surgical Problems. J Pain Symptom Manage. 2017;53(4):711-719.e5. doi:10.1016/j.jpainsymman.2016.11.014.
Makdisi G, Wang IW. Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology. J Thorac Dis. 2015;7(7):E166-E176. doi:10.3978/j.issn.2072-1439.2015.07.17.
Manthous CA, Ivy M. Why surgeons can say “no”: Exploring “unilateral withholding.” Journal of Hospital Medicine. 2011;7(3):249-253. doi:10.1002/jhm.986.
McIlvennan CK, Wordingham SE, Allen LA, et al. Deactivation of Left Ventricular Assist Devices: Differing Perspectives of Cardiology and Hospice/Palliative Medicine Clinicians. J Card Fail. 2017;23(9):708-712. doi:10.1016/j.cardfail.2016.12.001.
Meltzer EC, Ivascu NS, Acres CA, et al. Extracorporeal membrane oxygenation in adults: a brief review and ethical considerations for nonspecialist health providers and hospitalists. J Hosp Med. 2014;9(12):808-813. doi:10.1002/jhm.2262.
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Nakagawa S, Garan AR, Takeda K, et al. Palliative Care Consultation in Cardiogenic Shock Requiring Short-Term Mechanical Circulatory Support: A Retrospective Cohort Study. J Palliat Med. 2019;22(4):432-436. doi:10.1089/jpm.2018.0393.
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Disclosures
The following individual(s) has/have reported financial or other relationship(s) with commercial entities whose products/services may relate to the educational content of this activity:
Presenters
-
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Savitri Fedson, M.D., M.A.
Associate Professor
Baylor College of Medicine
Disclosure:
Nothing to disclose.
-
Mary Moubark, B.S.N., R.N., CCRN RNIII
Critical Care Registered Nurse
Houston Methodist Hospital
Disclosure:
Nothing to disclose.
-
Joanna Smolenski, Ph.D.
Assistant Professor, Center for Medical Ethics & Health Policy
Baylor College of Medicine
Disclosure:
Nothing to disclose.
Activity Directors
-
Holland Kaplan, M.D.
Assistant Professor
Baylor College of Medicine
Disclosure:
Nothing to disclose.
-
Janet Malek Weinstein, Ph.D.
Associate Professor
Baylor College of Medicine
Disclosure:
Nothing to disclose.
Planning Committee Members
-
-
-
Trevor Bibler, Ph.D.
Assistant Professor
Baylor College of Medicine
Disclosure:
Nothing to disclose.
-
-
-
-
David Garvis, Ph.D.
Clinical Ethicist
Baylor St. Luke’s Medical Center
Disclosure:
Nothing to disclose.
-
-
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Claire Marie Violaine Hoppenot, MD
Assistant Professor
Baylor College of Medicine
Disclosure:
Nothing to disclose.
-
Claire Horner, J.D., M.A.
Assistant Professor
Baylor College of Medicine
Disclosure:
Nothing to disclose.
-
Holland Kaplan, M.D.
Assistant Professor
Baylor College of Medicine
Disclosure:
Nothing to disclose.
-
Janet Malek Weinstein, Ph.D.
Associate Professor
Baylor College of Medicine
Disclosure:
Nothing to disclose.
-
Victoria McCurry, MD, FHM, FAAFP
Assistant Professor of Family and Community Medicine
Baylor College of Medicine
Disclosure:
Nothing to disclose.
-
Susan M. Miller, M.D., M.P.H.
Professor and Chair, General Internal Medicine
Houston Methodist Hospital
Disclosure:
Nothing to disclose.
-
Joanna Smolenski, Ph.D.
Assistant Professor, Center for Medical Ethics & Health Policy
Baylor College of Medicine
Disclosure:
Nothing to disclose.
Moderator
-
Janet Malek Weinstein, Ph.D.
Associate Professor
Baylor College of Medicine
Disclosure:
Nothing to disclose.
Health Topics
Presenters: