Who decides in withdrawal of treatment in a critical care setting? A case study on ethical dilemma.

CASE DESCRIPTION: Withdrawal of treatment is a common practice in critical care settings, perticularly when treatment is considered futile. The case study demonstrates an ethical dilemma, in which Danny is unlikely to make a functional recovery because of multiple organ dysfunction syndromes. Under such a circumstance, withdrawal of treatment will inevitably be considered, although his family refused to do so. Consequently, acritical question must be answered: Who should make the decision? ETHICAL DILEMMA IDENTIFICATION: Danny decided to withdraw the use of life-support, whilst his wife and adult children refused to do so. The ethical dilemma is illustrated by the following question: Who decides the withdrawal of treatment in a critical care setting? ANALYSIS: To provide an opotional solution to this case and make the best moral decision, the current study will critically discuss this issue in conjunction with ethical principles, philosophical theories and the values statement of the European and Chinese nurses' codes of ethics. Additionally, the associated literature relative to this case are analysed before the decision-making. ETHICAL DECISION-MAKING: The best ethical decision is Danny can decide whether to withhold or withdraw life-sustaining treatment. If his family is involved in the discussion, the medical staff should balance the ethical principles when they make the decision and allocate reasonable resources for patients.
RESULTS: In Danny's case, health professionals opted to respect his decision to withdraw treatment. The medical staff maintained an effective communication with the family involved, and provided the appropriate intervention to collaborate with other health care professionals to perfect further care.

Introduction

Critical care settings have been shown to benefit patients who are medically unstable and suffer potentially life-threatening diseases [1]. In a critical care setting, patients often fail to respond to the therapy or become considerably exhausted for interventions [2]. Under such a circumstance, the withdrawal of treatment will inevitably be considered. The literature defines ‘withdrawal of life-sustaining treatment’ as the end of medical therapy (e.g. antibiotics, mechanical ventilation, vasoactive drugs) with a clear intent not to choose substitute treatment [2]. However, this concept is different from withdrawal of care. Evidently, providing care for patients and ensuring comfort is as important as aggressive treatment. The Australian and New Zealand Intensive Care Society claimed that the withdrawal of medical therapy happens for several reasons [3]. Firstly, patients fail to respond to therapy (e.g. persistent multiple organ dysfunction) despite continued optimal treatment. Secondly, several acute diseases, such as cardiac arrest or brain damage, lead to severe mental and physical disabilities and other poor outcomes. Thirdly, poor prognosis of chronic diseases means an unlikely prolonged survival, such as in the case of end-stage cardiopulmonary disease, in which patients experience discomfort. Additionally, continuously prolonging the process of dying is painful for patients because it goes against the ethical principles of non-maleficence and beneficence. However, the lack of widespread policies to guide us leads us to a critical question: Who should make the decision to withdraw treatment? When nurses face this situation, they feel confused and are unsure of what to do. Evidently, the decision to withdraw life-prolonging therapy is difficult because such decision should be carefully considered and evaluated. In Europe, the relationship between the physician and patient is extremely paternal: decisions are generally made by the health care provider (54%) and the patients' relatives (44%); however, patients have extremely minimal participation in the process (0.5%) [4]. In Canada and the US, medical service has moved from paternalism to decision-making in an accountable manner [5]. Patients are informed and able to make decisions related to declining therapy or withdrawing treatment. Historically, respects for the sanctity of life and medical beneficence have been described in philosophical and ethics writings. Several valuable elements are involved in making ethical decisions, including code of ethics, understanding of ethical principles and ethics of caring [6]. The Code of Nursing and Midwifery Board of Ireland [7] indicate that nurses advocate for patients' rights and have respect for the dignity of patients. This topic involves the principles of autonomy, non-maleficence, beneficence and justice and will be critically analyzed in the current study. Traditionally, medicine has focused on withholding therapy and extending life [8]. However, this field needs to think to maintain life for long periods when patients lack any hope of recovery. Romayne claimed that care should make patients feel comfortable and peaceful [8]. Medical staff members and families should respect patients' autonomy and balance the withholding and withdrawal of treatment. The aims of this study are to discuss who would make the decisions and promote safe ethical practice.

The principles of autonomy, beneficence, non-maleficence and justice should be considered in exploring the moral considerations inherent in decision-making related to the withdrawal of treatment [9]. In practice, ethical principles may play a role in overcoming ethical dilemmas. The following scenario illustrates the contention amongst the four principles to determine who should make the decision in withdrawing treatment.

Case introduction

Case description

Danny was a 77-year-old retired government executive, who had free health care services. He was diagnosed with chronic obstructive pulmonary disease (COPD) and prostatic cancer for 10 years. He was sent to the Emergency Department because of pneumonia and heart failure. Doctor Derry had him transferred to the intensive care unit (ICU) because he needed to be intubated and given support by a mechanical ventilator and antibiotic therapy. Prior to intubation, Doctor Derry told Danny that weaning the ventilator and returning home may no longer be possible. Danny understood and agreed because his wife was not in good health and could not take care of him at home. Danny also expressed that he did not want full cardiopulmonary resuscitation. Danny was intubated and placed on the ventilator and the regular course of antibiotic treatment of the pneumonia proved successful. However, the medical staff failed to wean him from the ventilator for three weeks. The doctor prepared to transfer him to the respiratory ward where chronic ventilated support could be continued. Twelve days after this procedure, Danny told his nurses that he strongly desired to be removed from the ventilator. He could no longer bear the ventilated treatment and thought it would result in his death. Doctor Derry discussed the situation with Danny's wife and adult children. The doctor also told Danny that his functional recovery was no longer likely because of multiple organ dysfunction syndrome. Danny's cancer also means that intensive care is simply extended life or postponed death. Danny's wife and adult children felt extremely sad and refused withdrawal of treatment because they did not want to lose him. Ten days later, Danny told his wife that the cancer caused him pain and he had difficulty breathing even whilst taking sedation medications. Accordingly, there were things worse than dying. He feared experiencing distress in breathing and would prefer simply to die in his sleep. His wife said nothing but held his hand and began to cry. Eventually, Danny strongly asked Doctor Derry for the withdrawal of ventilation and passed away 24 hours later.

Ethical dilemma from this clinical case

This case indicates that Danny's condition of multiple organ dysfunction syndrome means that he had to depend on mechanical ventilation for a long time. The patient wanted to end his life because of the lack of hope for recovery. However, his wife and adult children refused withdrawal of treatment. In China, medical staff members could provide professional advice that might influence the decisions of patients and their families. However, a patient's autonomy would be violated. Thereafter, the ethical dilemma of Danny's case can be identified through the following crucial question: Who can make the decision if a patient wants withdrawal of treatment in a critical setting?

Analysis of the ethical dilemma

Ethical principles applied to this case

Principle of beneficence

Beneficence means actions that can benefit the patient or others [10]. Specifically, the benefit may be physiological or psychological [5]. When a medical therapy improves a patient's condition, the treatment provides a real benefit. When a psychological support achieves certain relief for the patient, such treatment is also considered a benefit. In the current case, the doctors had exerted their best effort to help Danny and constantly communicate with him. However, Danny still wanted to end his life because he thought that he no longer had hope for recovery. Additionally, he could not tolerate the pain and experienced distress in breathing. Traditionally, medical staff members would provide life-sustaining measures to prolong a patient's life [11]. However, the benefit cannot merely keep the patient alive because it needs to maintain status without further deterioration [12]. If a reasonable prospect for recovery is unavailable, then the health care providers must consider all the related factors. Occasionally, palliative care would be a better choice than active treatment. In the current case study, the patient feels that the treatment is painful, but withholding treatment may cause more harm to the patient. Beneficence should be a positive requirement to produce more good than harm to others. Health care providers could provide suggestions and psychological support that will enhance the quality of life of patients. Overall, a patient's wish must be respected firstly, even if doing so does harm to them, thereby underpinning the concept of patient autonomy.

Respect for autonomy

Autonomy means respect for the patients' capability to make decisions on their own life or health [10]. The Health Information and Quality Authority reported that autonomy is a general principle of medical practice, in which patients have the right to refuse or accept treatment [13]. A patient with this capability can decide whether to withhold or withdraw life-sustaining treatment [14]. Meanwhile, patients' values and beliefs will influence their decisions [15]. Therefore, the health care provider is responsible for communicating with them in practice; balancing rights, risks and responsibilities and implementing supportive actions [13]. In Danny's case, Doctor Derry had told him before intubation that weaning the ventilator and returning home may no longer be possible. At that time, Danny understood and agreed because he could not predict the painful process. However, he wanted to give up when he experienced that he could no longer tolerate the ventilated treatment. Moreover, Danny's wife was not in good health and could not take care of him at home. Consequently, he balanced the benefit and harm and made the decision to withdraw treatment. Health care providers consider decisions from the disease aspect, but patients based theirs on the impact on their life. Danny expressed that he did not want full cardiopulmonary resuscitation because he believed that prolonging his life was meaningless. The medical staffs also need to implement and evaluate supportive actions for patients apart from respecting their right to autonomy [13]. However, respecting a patient is different from following a patient's choice. Respect is considering a person's wishes and decisions in a judicious manner, as well as providing support. Additionally, the decisions are reasonable and beneficial to keep the patient comfortable. By contrast, “following” simply means doing what the patient tells which can be harmful. Hence, we introduce the concept of non-maleficence to prevent harm to patients.

Principle of non-maleficence

Non-maleficence refers to actions that do not bring harm to patients and others [10]. Health care providers aim to practice this ethical principle and hold it foremost in their practice. However, a disparity in perspective may exist in many medical therapies [14]. For example, ventilated treatment, CPR and prolonging and withdrawal of treatment rapidly may be harmful to patients. To reduce the risk of harm to patients, health care providers should consider the former's condition and likely prognosis. Meanwhile, this information should be communicated with patients and their relatives. The Queensland government [5] stated that the unwillingness to withhold or withdraw life sustaining measures may also cause harm because patients lack the ability to adapt to the invasive treatment or aggressive therapy. In the current case, Danny was diagnosed with COPD and prostatic cancer over the course of 10 years. Accordingly, his dependence on ventilated treatment has prevented him from having a quality life. Although a mechanical ventilator and antibiotic therapy were effective in maintaining Danny's breathing, such treatment could not prevent the progress of multiple organ dysfunction. Danny told his wife that he felt pain and experienced difficulty in breathing even when he received sedation medications. Evidently, the continuous prolonging of the process has caused physical and mental suffering. The patient had expressed these views because he regarded the intervention as harmful. His wish must also be considered in the decision-making process. In relation to this issue, the following questions must be answered: Should healthcare professionals respect patient choices without question? What is the role of professional responsibilities in this issue? The concept of justice can provide the answer to these questions.

Principle of justice ethical dilemma

Justice means being fair to the wider community. All health professionals should treat every patient in the same manner [10]. On the one hand, these professionals should maximise the available resources and provide equity of opportunities for patients. On the other hand, the inadequate supply of ICU beds results in difficult decisions on which patient should be given medical service. Hence, health care providers should balance decisions on resources and allocate them to patients in need, as well as recognise that decisions that provide benefit to one may result in harm to another. In this case, Danny was a retired government executive and had free health care services. The continuous development of technology has provided opportunities to maintain or prolong life for a long time through life-sustaining measures [16]. In terms of an individual's right, Danny could enjoy the medical resources. However, no reasonable prospect of recovery was available. Inevitably, clinicians should distribute the scarce ICU beds based on the available prognostic data of patients. That is, patients who should benefit the most from medical services are those who should receive such services. In this case study, maintaining the life of Danny may likely prolong the dying process of using the limited medical resources.

China is a human-relations society [17] and numerous health professionals experience difficulty in implementing the related measures, thereby resulting in the deterioration of the relationship between medical staff members and patients. Hence, ineffective treatment frequently occurs owing to the lack of corresponding laws and regulations. As such, laws and regulations on the aforementioned life-sustaining treatments should be implemented to address the appropriate delivery of life-limiting disease.

European countries’ nurse code of ethics vs. Chinese nurse code of ethics

Apart from analysing ethical dilemmas from the perspective of the four principles, another model that can be used is the code of ethics. The Code of Ethics and Conduct for European and Chinese Nursing [18,19] presents several common values: respect for human rights and human dignity, promotion of nursing excellence and public protection, source of information for nursing professionals, development and maintenance of professional competences and patient safety and public protection, amongst others.

However, different cultures have varying values and beliefs. Hence, codes of ethics vary across a variety of contexts in different countries. In Ireland, ‘respect for the dignity of the person’ is claimed from the Universal Declaration of Human Rights [20]. ‘Nurses and midwife's advocacy for patients' rights' has been described in the Nursing and Midwifery Board of Ireland [7], which claims that all patients have a right to make their own healthcare decisions. Medical staff members should respect the patients' right to self-determination and informed consent should be applied when decisions are made. In Danny's case, if he decides to withdraw treatment, then neither the health care providers nor his family can deny his decision. Only Danny has the right to self-determination, decide whether to accept nursing care or refuse to receive information, suggestions or assistance. Consequently, nurses must respect his personal decisions.

In China, the ethical code of nurses states that respect is demanded for patients and their families [18]. Nurses should arrange and use the existing resources with flexibility and offer the best service to patients and their families. Phua et al. claimed that the Chinese often withheld but seldom withdrew life-sustaining treatments at the end of life compared with their European counterparts [17]. Multiple factors, including economic, religious and cultural, as well as individual attitudes, were also related to these variations. In Danny's case, he is a 77-year-old retiree. The traditional Chinese value of filial piety makes it difficult for adult children to forgo life-prolonging treatment [20]. The lack of autonomy occasionally results in patients' wishes not receiving the corresponding respect. Therefore, nurses should offer care, consultation and guidance to patients and their relatives. Moreover, these services should be based on individual cases and that the demands of patients should be respected. The families of patients should be encouraged to get involved in care planning and implementation. Such involvement is also an important component of the Chinese nurses' ethical code.

Application of ethical theory on this case study

The withdrawal of treatment is a sensible topic in moral philosophy. Mandal et al. expressed that deontological and utilitarian theories are relevant in ethics related to decision-making: utilitarianism is society-centred, whereas deontological ethics is patient-centred [21,23]. Utilitarianism is often guided by the considered harms or benefits for evidence-based intervention. In utilitarianism, every decision will balance the benefits and harms firstly [22], thereby often leading to waste of resources and time in decision-making. However, achieving the maximum benefit could lead to harm in a few patients. In Danny's case, the withdrawal of a ventilator is a utilitarianism choice because the limited resource can save more lives and reduce the morality of the medical organisation. However, the harm is unacceptable for Danny's wife and adult children. Compared with utilitarian, deontology is an approach to ethics that focuses on the rightness or wrongness of actions themselves and not the consequences. The decisions may just focus on an individual but not the outcome for society. Empathy and perspective-taking are associated with deontological [24] because they can assist medical staff members to understand what patients want and need. In Danny's case, he cannot have a quality life. That is, prolonging the process causes physical and mental suffering. Accordingly, health care professionals should respect patients' choices and develop intellectual adaptability. Evidently, a balance between deontological and utilitarian would bring better justice and harmony to the medical service.

Opinion in the associated ethical leadership of this case study

Ethical leadership respects ethical beliefs and values and focuses on the dignity and rights of patients [25]. This type of leadership is related to such concepts as autonomy, trust, consideration and justice. However, leadership is also vital to foster a patient-centred or patient-safe ethical environment in health care organisations. The withdrawal of treatment is a complex decision-making process that involves patients, relatives and health care providers.

The National Advisory Group suggests that National Health Service (NHS) leaders respect patients' dignity and rights and implement the principle in all management and staff levels [26]. High-quality leader–member relationships are associated with a positive workplace culture environment [27]. To form a patient-centred culture, decision-making pathways have been built in a few countries, such as Australia and New Zealand [3]. The support of leadership will enable medical teams to learn additional skills and improve their individual ethical capabilities [28]. In critical settings, the withdrawal of treatment may lead to patients dying immediately, whilst a few patients will opt to leave the hospital. All interventions should be individualised to the needs of the patients and their families. Medical staff members, as moral agents, should develop ethical capabilities to facilitate the perceived outcomes for the patients and their family members. Regulation is insufficient. Ethical sensitivity enables health care providers to act ethically in the services [29]. Therefore, ethical leadership plays an important role in developing moral responsibility and forming an ethical team in healthcare organisations.

Results

In Danny's case, health professionals chose to respect his decision to withdraw treatment. The medical staff maintained an effective communication with his family and provided the appropriate intervention to collaborate with other health care professionals to prefect the further care. Once, the medical staff observed the lack of cure for Danny. They likewise provided information on all the treatments and outcomes to Danny and his family. Meanwhile, health professionals have developed further psychological plan. In China, only a few families take the initiative to withdraw treatment for their loved ones, particularly for their aging parent. Evidently, Danny's family should know his true wishes, thereby influencing the decision-making process. Indeed, the critical illness caused Danny to feel pain, which is even worse than dying. The medical team provided additional visiting hours to Danny's family. When Danny eventually asked to withdraw treatment, his family remained by his side until he passed away.

Conclusion

Withdrawal of treatment is a complex decision-making process. In such a circumstance, a patient's autonomy is critical in decision-making. The general principles of law and medical practice indicate that people have a right to decide. In a few cases when a patient is no longer capable, the family should be informed on the former's ‘treatment options in an honest way’. That is, a patient's family should be involved in the discussion to enable them to provide their opinion. Health care professionals should balance the ethical principles of autonomy, beneficence, non-maleficence and justice when they make the decision and allocate reasonable resources for patients. A few moral theories have been applied to explain the decision-making process. Utilitarianism entails that every decision is guided by the desire to achieve maximum benefit, whereas deontology is an approach to ethics that focuses on the individual. With empathy and perspective-taking, medical staff members will consider the patients' benefits and interests when they make the decisions. Apart from ethical regulation, moral integrity and ethical sensitivity also play an essential role in healthcare organisations. Medical staff members should act ethically and do the right thing because it is the correct thing to do and not mandated. With the support of ethical leadership, medical staff members, as moral agents, should develop their ethical capabilities. Once an ethical team is formed, it would promote a safe ethical practice and enhance harmony in the medical service.

Author contribution

The author make all contribution associated with this article. The author sets up the conception and design of the study, collect and analysis the data, drafting and finish the article, and approves the version to be submitted.

Conflicts of interest

The authors did not have a conflict of interest in the preparation of this paper.

Ethical approval

None.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.