Withholding and Withdrawal of Life Support from Critically Ill Patients: Medical Opinions Regarding Withholding or Withdrawing SupportMedical Opinions Regarding Withholding or Withdrawing Support
Most of the court cases cited regarding withholding or withdrawal of life support were brought by patients or their proxies against physicians and medical institutions for failing to withhold or withdraw support. Furthermore, most of the legislation cited earlier has been advanced by the legal and not the medical profession. Whatever the reasons for this situation, it is widely perceived that the medical profession has occupied a right-to-life at all costs position in defiance of growing public sentiment for patient autonomy and the right to die. Yet despite this perception, physicians have become increasingly outspoken in their desire to withhold and withdraw life support in certain circumstances through the Presidents Commission, personal writings, and position papers in medical literature. Among the most important of these statements have been “Optimum care for hopelessly ill patients,” “The physicians responsibility towards hopelessly ill patients,” and “Initiating and withdrawing life support,” all of which were published in the New England Journal of Medicine. These papers argue persuasively for withholding or withdrawing therapies ranging from mechanical ventilation to fluids and nutrition from patients with terminal illnesses and irreversible coma or the persistent vegetative state, especially if the families agree. Read the rest of this entry »

Use of Advance Directives
In all the cases cited earlier, the courts have endorsed the use of patients’ previously stated wishes regarding life support and the validity of patient proxies in articulating these wishes or deciding for the patients when their wishes are not known. In parallel with these judicial actions, private individuals have chosen to communicate their wishes through living wills. These documents, which may be classified as instructional directives, are least effective when their language is vague and they are applied to patients with uncertain prognoses. Nevertheless, living wills can add greatly in clinical decision making. Unfortunately, the documents are of dubious legal reliability when not legislated by the respective state; in Florida, the first State Appellate Court to review the issue of living wills in, In the Matter of Francis Landy (1983), ruled that a living will that was not approved by the state legislature cannot be the basis for withholding or withdrawing life support. Read the rest of this entry »

Withholding and Withdrawal of Life Support from Critically Ill Patients: TherapiesThe celebrated case of Barber v Superior Court (1983) confirmed the utility of “substituted judgment” and also answered the question of physician liability in withholding or withdrawing life support. This case involved two California physicians who performed surgical closure of an ileostomy on Mr. Herbert, who subsequently suffered cardiopulmonary arrest. Five days later they determined that his coma was irreversible and, with the consent of his family, withdrew not only mechanical ventilation but also intravenous fluids and nutrition. Although the family found no fault with this at the time, the physicians were accused of murder by a district attorney After the case was heard by several courts, the California Court of Appeals ruled that the physicians had not failed to perform their duty because they considered it medically futile to continue life support. Read the rest of this entry »

The American judicial system, which has supported the concept of brain death as described earlier, also has been instrumental in shaping public attitudes and social policy in the area of withholding or withdrawing support from patients who are not brain dead. In the process, the courts have underscored the importance of privacy and the right to refuse treatment. They have also contributed to the concept that human life is more than a biologic process, defined how therapies may or may not benefit patients, argued against a distinction between withholding and withdrawal of support, and established guidelines for how support may be withheld or withdrawn. Read the rest of this entry »

Withholding and Withdrawal of Life Support from Critically Ill Patients: CNSThis concept was appealing, because it recognized the integrative function of the central nervous system (CNS), without which there can be no breathing or heartbeat. The legal propriety of brain death was upheld in the case of Tucker v Lower (1972), in which a Virginia court found that physicians who removed Bruce Tucker from a ventilator in order to transplant his heart were not guilty of a wrongful determination of death. Since then, the Presidents Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research has recommended a uniform determination of death statute; 37 states plus the District of Columbia have passed brain death statutes, and several of the nonstatute states have acknowledged the propriety of withholding or withdrawing life support from the brain dead. Furthermore, policies of “required request” were enacted in 1986 in California, Oregon, and New York requiring that physicians bring up the issue of organ donation with the families of patients with brain death. Read the rest of this entry »

Despite the factors that influence physicians to treat critically ill patients whenever possible, the idea that life must be supported at all costs has become increasingly less persuasive in the ICU. One reason for this is dissatisfaction with the technologies that have given to ICU its present prominence; a case in point is the pulmonary artery catheter. At the same time, the evolution of critical care medicine as a specialty represents in part an attempt to concentrate medical responsibility in a few physicians who are knowledgeable about withholding and withdrawing life support, among other things. Retrospective reimbursement for hospitals has been replaced by prospective, uniform payment for Medicare patients and may discourage the intensive care of these persons. Similarly, as more physicians become salaried and less financially dependent on performing procedures, they may be disinclined to favor ICU admission. Support for this position comes from several studies demonstrating the limited therapeutic benefits of critical care. Read the rest of this entry »

Determination of Total Respiratory Resistance in Health and Disease by Added External Resistance: MethodsWith the solenoid deenergized, the subject is asked to breathe normally in and out of the device. When expiratory flow rate is at or just past maximum the solenoid is energized. This “closes the shutter” puts in series with R„, and always causes a characteristic notch in the flow tracing (Fig 4). Referring to equation 6 and Figure 4, flow at the upper left corner of the notch serves as V. Since preliminary studies showed the presence of oscillations in flow during the first 30 to 40 ms after the shutter began to close, AV was measured 0.05 s after the beginning of the notch. In both normal subjects and patients with COPD, 0.05 s was sufficient time for flow to stabilize at a new, lower value. Read the rest of this entry »

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