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Discontinuation of Life-Sustaining Therapies 

Discontinuation of Life-Sustaining Therapies
Chapter:
Discontinuation of Life-Sustaining Therapies
Author(s):

Kathy Plakovic

DOI:
10.1093/med/9780190204709.003.0010
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date: 23 September 2018

Key Points

  • Withholding and withdrawing antibiotics, blood products, dialysis, and artificial nutrition are important topics that require shared decision-making.

  • The benefits and burdens of treatment versus no treatment should be explained to the patient and family, along with the ethical framework that supports either decision.

Consensus Regarding Prognosis

The goal of withdrawing treatments is to allow the natural process of death to proceed instead of prolonging the dying process with treatments that may offer little benefit (and potentially high burdens) to the patient. It is important that there is consensus among healthcare providers regarding the prognosis before discussing it with patients and families. Obtaining consensus can be difficult because physicians are often overly optimistic in their prognosis.1 Prognostic scoring systems, such as the Palliative Prognostic Score (PPS),2 can assist clinicians in determining a prognosis for patients with diseases like cancer at the end of life.

Discussions should take place with patients and families regarding the prognosis with or without continued treatment. Patients with decision-making capacity can elect to forgo or withdraw life-sustaining treatment. For patients who lack capacity, their healthcare power of attorney or legal surrogate decision-maker can elect to withhold or stop treatment.

Antibiotics

Antibiotic use is common and is considered the standard of care for patients with an infection. Using antimicrobial medications at the end of life is a common practice.3 As with other life-sustaining treatments, the decision to withhold or withdraw antibiotics requires informed decision-making based on the goals of care for the individual patient. Table 10.1 offers the source of infections when considering continued antimicrobial use.

Table 10.1 Likely Symptoms or Sequelae at End of Life

Infection Site

Associated Symptoms

Urinary tract

Dysuria, fever, frequency, pain

Respiratory tract

Cough, dyspnea, fever, sputum production

Mouth/pharynx

Fever, mucosal inflammation/pain, odynophagia

Skin/subcutaneous

Fever, pain, skin rash/discoloration

Blood/bacteremia

Fever, disorientation, hypotension

Portions from reference 4. Reprinted with permission from Elsevier.

Blood Products

Transfusion of blood products, including red blood cells and platelets, is a life-sustaining treatment for patients with anemia and thrombocytopenia due to the disease process or treatment-related cytopenias. Often, many of these patients have hematologic malignancies and blood transfusions are a quality-of-life measure. Since their condition is difficult to predict, it is helpful to have a guideline to prognosis (Box 10.1). Many patients with advanced disease become transfusion-dependent due to bone marrow infiltration or chronic bleeding from tumor invasion. For these patients, continued transfusions are used not as a bridge to wellness but as a temporary measure.

Adapted from reference 5. Reprinted with permission from Springer.

Continuing transfusions in terminally ill patients can place a tremendous burden on the patient and family and usually requires frequent clinic visits for laboratory tests and transfusions, which can result in unplanned hospitalizations. Patients requiring frequent transfusions are at risk for fluid overload, transfusion reactions, and alloimmunization, making matched transfusions more difficult. Routine transfusions based on complete blood count results showing anemia or thrombocytopenia should be discouraged. Box 10.2 offers considerations for continued blood product use if a patient has end-stage disease.

Adapted from reference 6. Reprinted with permission from Wiley.

Dialysis

Use of the Renal Physicians Association/American Society of Nephrology Guidelines for the Initiation and Withdrawal of Dialysis can help guide discussions with patients and families regarding the appropriate time to start or stop treatment.7 Prognosis can be difficult to predict for patients with end-stage renal disease (ESRD) once dialysis is initiated. Clearly, there is a survival benefit to initiating treatment versus withholding. However, discussing the short-term prognosis with patients and family members can aid in decision-making. Table 10.2 offers a mortality risk assessment for patients with ESRD.

Table 10.2 Points Assigned to Each Risk Factor for Mortality in ESRD

Risk Factors

Points

Body mass index (kg/m2) <18.5

2

Diabetes

1

Congestive heart failure stage III or IV

2

Peripheral vascular disease stage III or IV

2

Dysrhythmia

1

Active malignancy

1

Severe behavioral disorder

2

Totally dependent for transfers

3

Initial context of dialysis unplanned

2

Adapted from reference 8. Reprinted with permission from Oxford University Press.

It is important for patients and families to understand the prognosis with and without dialysis, so they can make informed decisions. Patients with ESRD who discontinued chronic dialysis had a mean survival of 7.8 days.9 Patients with acute kidney injury (AKI) who withdraw from treatment have a much shorter life expectancy.10 Patients and families can be counseled that death from uremia is usually peaceful because it induces coma. Symptoms like pain, myoclonus, dyspnea, or secretions can occur, and their management should be a priority.

Nutrition

Families can have strong feelings about “feeding” patients and worry that without artificial nutrition the patient will “starve to death.” Moreover, nutrition and eating and drinking may be considered a human right and part of reasonable care for patients. Nonetheless, total parenteral nutrition (TPN) has a limited role in advanced cancer patients. Bowel obstruction occurs in 25–50% of patients with advanced gynecologic cancers.11 Venting gastrostomy tubes are commonly placed in patients with malignant bowel obstruction for symptomatic relief. There are conflicting data as to whether TPN after gastrostomy tube placement for bowel obstruction provides any survival benefit.

Anorexia is a natural part of the dying process. Patients generally lose their desire to eat as death nears. Often families will request enteral feeding via a nasogastric or percutaneous endoscopic gastrostomy (PEG) tube. The American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines for nutritional support in cancer patients state that “the palliative use of nutrition support therapy in terminally ill cancer patients is rarely indicated.”12

The burdens of continuing TPN include ongoing monitoring of laboratory values, electrolyte imbalances, and pancreatic and liver dysfunction,13 as well as edema and worsening respiratory secretions. Patients also incur risks associated with ongoing central venous access, such as line infection leading to sepsis, thrombotic occlusion, and dislocation of the catheter.14

Conclusion

Life-sustaining treatments, such as antibiotics, blood products, dialysis, and artificial nutrition, can prolong the dying process in critically and terminally ill patients. These treatments may provide little benefit, and the burdens of these interventions can increase suffering. See Table 10.3 for consideration of withdrawal of these life-sustaining therapies.

Table 10.3 Sequelae of Withdrawal of Specific Life-Sustaining Therapies

Life-Sustaining Treatment

Likely Sequelae and/or Symptoms from Withdrawal

Antibiotics

Fever, delirium, cough, dyspnea, hypotension, somnolence

Blood products

Fatigue, weakness, shortness of breath

Dialysis

Pruritus, pain, myoclonus, dyspnea, secretions

Total parenteral nutrition

Hypotension, somnolence

Portions from reference 4. Reprinted with permission from Elsevier

Families are often faced with decisions regarding withholding or withdrawing life-sustaining treatment as patients near the end of life. Recommendations regarding withholding or withdrawing treatments should be made based on medical knowledge and evidence-based practice.

References

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