5.1 Appropriate Use of Life-Sustaining Treatments
UNDER REVIEW - The following three cases are under review (5.1 / 5.2 / 5.4) in light of the Supreme Court decision in Carter v. Canada (Attorney General), 2015 SCC 5. (Date: 2015/02/06).
Natalie Bandrauk, MD, MSc, FRCPC
- To recognize the importance of discussing reasonable goals of care at the end of life
- To review the ethics of withholding and withdrawing life-sustaining treatment
- To consider the challenges and strategies of discussing and providing high quality end-of-life care in acute care situations
A 90-year-old man arrives in the emergency room by ambulance. At the original scene of the emergency, the patient was unresponsive, blue and asystolic. Cardiopulmonary resuscitation was begun, and a weak pulse was regained en route to the hospital. The patient had choked on food, and the paramedics are having trouble bagging him. As the emergency room physician, you do your preliminary survey (ABCs) and remove the food from the airway. The patient is unresponsive but has a rhythm and a low blood pressure.
What do you think should be done? Why?
What other information might be relevant to your decision-making process?
The ambulance record shows eight minutes between the call and the paramedics' arrival on the scene, and a few more before a rhythm was obtained.
Does this information change your plan?
According to the man's 89-year-old wife, when the patient choked he started to gasp but then fell limp. With the assistance of a home care worker, she laid him on the floor and tried to stimulate him. It was about five minutes before they called 911.
At baseline, the patient required home care because of decreased mobility and had some memory loss.
- What moral principles come into play in this scenario?
- Is there a difference between withholding and withdrawing a treatment?
- How do you approach the family, and what should you discuss with them?
- Why might the physician recommend conservative care?
- Why might a family wish to withdraw life-sustaining treatment? Why might a family request aggressive care?
- Why might the physician agree to continued aggressive care?
- What approaches have you witnessed that worked well in such situations, or what approaches have not worked?
This case should be used as a starting point to consider and to navigate through the different options provided by modern medicine, the justifications for choosing a certain path and the different viewpoints that might lead to a different path. The goal is to learn how to work with patients and families to achieve good end-of-life care and to avoid conflict, rather than assuming it is there and practising defensive medicine. When families are approached in such situations, responses can be unpredictable. It is important to have an approach and to anticipate several issues the family may raise.
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