Withholding Life-Sustaining Intervention

Policy Statement

In accord with the Ethical and Religious Directives for Catholic Health Care Services, the goal of this Hospital is to restore health and relieve suffering when possible through the use of all appropriate means available. In addition, this Hospital never intends to impose unwanted burdens on those whom it serves. This Hospital recognizes that an adult patient’s fundamental right to control decisions requiring his/her medical care includes the right to decide to have life-sustaining procedures withheld or withdrawn under certain conditions. It is the policy of this Hospital to respect patient autonomy and the decision to forego life-sustaining intervention. This Hospital respects the dignity of both patients and caregivers and supports the decision made by the individual.

Definitions

Life-sustaining intervention: "...any medical intervention technology, procedure, or medication that is administered to a patient in order to forestall the moment of death, whether or not the intervention is intended to affect the underlying life-threatening disease(s) or biologic process." (Reference "Guidelines on the Termination of Life, Sustaining Treatments and Care of the Dying," Hastings Report, 1987.)

Life-sustaining intervention can include, but is not limited to, resuscitative measures, mechanical ventilation, medicines for maintaining blood pressure, medicines for prevention of arrhythmias, blood transfusions, antibiotics, hemodialysis, chemotherapy, surgical procedures, intravenous or enteral hydration and nutrition.

Advance Directive - An advance directive, such as the Advance Healthcare Directive, is a written or oral instruction that relates to the provision of healthcare when the individual is unconscious, incompetent, or in a permanent vegetative state. These procedures are intended to enable this Hospital to comply with the Patient Self-Determination Act, as contained in the Omnibus Reconciliation Act of 1990 and the Health Care Decisions Act - AB 891.

Surrogate Decision Maker for Patients that Lack Capacity: The surrogate decision maker for a patient who lacks capacity is the agent appointed pursuant to an Advance Healthcare Directive, a conservator with healthcare decision making authority, or where there is none, the family or significant others. In the absence of an Advance Healthcare Directive, the healthcare provider seeking to identify the appropriate surrogate should consider immediate family members who: (1) are "in the best position to know (the patient's) feelings and desires (regarding intervention);" (2) "would be most affected by the (intervention) decision;" (3) "are concerned for (the patient's) comfort and welfare;" and (4) have expressed an interest in the patient (Barber v. Superior Court, 147 Cal.App.3d 1006, 1021 fn. 2 (1983). In addition to family members, it may be appropriate to rely on non-family members who meet these criteria.

Policy Interpretation

1. Patient as Decision Maker
1. The patient will be the decision-maker whenever possible. An adult with capacity may give informed consent regarding intervention decisions after having been fully informed of the benefits, risks and consequences of intervention options. This is true even when such decisions may result in the shortening of the individual's life.
2. A patient with capacity may direct the withholding or withdrawal of life-sustaining intervention after he/she has been informed of his/her diagnosis, prognosis, the nature of intervention, its expected benefits, its associated burdens, risks and complications, and any alternative treatments including their benefits and risks. A patient with capacity should assess the intervention's expected benefits and burdens. The patient's physician(s) should assist in this assessment.
3. The unique facts of each case must be considered and include:
1. How long the intervention is likely to extend life and if it can improve the patient's prognosis; provide access to any therapy that may realistically be expected to improve the patient's quality of life.
2. The nature of the patient's life such as the possibility of the return to cognitive life and the remission of symptoms enabling a return toward a functioning, integrated existence.
3. The degree of intrusiveness, risk and discomfort associated with the intervention.
4. The patient will be informed that he/she may execute an Advance Healthcare Directive.
5. The patient with capacity has the right to decide who will be informed of this decision.
   
   
2. Surrogate as Decision Maker
1. If a patient is unable to make healthcare decisions and has executed an Advance Healthcare Directive, life-sustaining procedures may be withheld or withdrawn in accordance with the patient's instruction. If the patient has executed a valid Advance Healthcare Directive, the designated agent is the surrogate decision-maker. A copy of the executed Advance Healthcare Directive must be placed in the patient's medical record.
2. In the absence of an Advance Healthcare Directive, and if the patient lacks capacity, and is unable to give informed consent or refusal, the healthcare providers and surrogate decision-maker will act in accordance with previously expressed patient desires, if known.
3. If the patient is a minor, his/her parents or guardian are the decision makers. (A minor is not presumed to lack capacity to participate in the decision making process solely on the basis of age.)
• In the case of a guardian, a copy of the certified letters of guardianship are placed in the patient's medical record.
4. If the patient is an adult for whom a conservator has been appointed with authorization to make healthcare decisions for the patient, the conservator is the decision maker.
• When there is a conservator with the authority to make healthcare decisions, a copy of the certified letters of conservatorship is placed in the patient's medical record.
5. It is the legal obligation of the surrogate decision-maker to carry out the advance healthcare directive of the patient (Probate code section 4714). In the case of a disagreement between the healthcare providers, stated advance healthcare directive, and surrogate decision-maker, the Bioethics Committee may be consulted.
6. If the patient's desires are not known, the surrogate acts in the patient's best interest by analyzing the comparative benefits and burdens of initiating and/or continuing intervention together with the patient's attitudes and beliefs. The patient's physician(s) should assist the decision-maker in this assessment. In general, intervention is to be provided unless the burdens imposed outweigh the benefits of the intervention to the patient. This comparison of benefits and burdens is dependent on factors unique to each case as outlined in I.C, above. Other relevant considerations for the surrogate decision-maker include:
1. Relief of suffering;
2. Preservation of restoration of functioning;
3. Quality as well as the extent of life being sustained;
4. Degree of intrusiveness, risk and discomfort associated with the intervention;
5. Impact of the decision on people closest to the patient.
7. Whenever possible, the patient's immediate family and significant others, as appropriate, will be consulted and their wishes will be given due consideration in arriving at the decision.
   
   
3. No Identified Decision Maker
   If no surrogate can be identified for an unbefriended patient, refer to Healthcare Decisions for Incapacitated Patients Without Surrogates policy.
   
   
4. Physician Responsibility
1. The treating physician and consulting physicians are responsible for determining the patient's diagnosis and prognosis. The physician(s) provides the patient or the patient's surrogate with the requisite information to enable him/her to evaluate an intervention's benefits and burdens. Decision- making is a process initiated by the physician; however, the final decision is the responsibility of the patient or the appropriate surrogate.
1. The treating physician(s) is not required to secure a second opinion.
2. A physician may choose to consult with another physician or the Bioethics Committee regarding the case.
3. The physician will provide the surrogate decision-maker with the same information that would be provided to a competent patient.
2. An order to withdraw or to withhold life-sustaining treatment must be written and signed by the physician on the physician order sheet in the patient's medical record. In the event a telephone order is given, it must be co-signed by a physician within 24 hours.
3. The orders and/or decision to withhold or withdraw life-sustaining intervention must be supported by complete documentation in the progress notes of all circumstances surrounding the decision. Such documentation includes, but is not limited to:
1. A summary of the medical situation which specifically addresses the patient's mental status, test results, diagnosis, and prognosis at the time the order is written or the decision is made. If no tests are performed, an explanation of such is documented.
2. The outcome of any consultation with other physicians. Physicians who provide consultation must document their consultative findings and recommendations.
3. A statement as to the basis on which a particular person (or persons) has been identified as the appropriate decision-maker(s) for patient who lacks capacity.
4. A statement summarizing the outcome of consultations with the patient, surrogate, family, and/ or significant others.
5. A statement describing how the physician established that there is an informed refusal of life- sustaining intervention. This statement could include documentation of discussions with a patient with capacity or a surrogate decision maker.
4. All decisions to withhold life sustaining intervention are re-evaluated by the primary physician as medically indicated in consultation with the patient/family or surrogate.
5. Every appropriate measure to relieve patient suffering and maintain patient comfort is provided. Dignity, hygiene and comfort of the patient is preserved, even if specific life-sustaining intervention is withheld or withdrawn. Patient comfort and dignity is of utmost importance.
6. Prior to the withdrawal of life-sustaining intervention, there may be a Palliative Care Consult and the patient will be assessed for level of consciousness and existence of discomfort by the MD/nurse. The patient will be treated for discomfort or pain prior to withdrawal of life-sustaining intervention. Once it has been determined through consultation by physician with patient/family/surrogate decision-maker, Palliative Care, Social Services, Chaplain Services, all medical interventions may be withdrawn if the patient is not an organ donor.
7. From Ethical and Religious Directives for Catholic Health Care Services, "Medicines capable of alleviating or suppressing pain may be given to a dying person, even if the therapy may indirectly shorten the person's life, as long as the intent is not to hasten death".
   
   
5. Risk Management Responsibility
   The hospital's Risk Manager, or his/her designee, shall be consulted before an order to withhold or withdraw life-sustaining intervention is issued whenever:
1. The patient's condition has resulted from an injury which appears to have been inflicted by a criminal act;
2. The patient's injury or condition was created or aggravated by a medical incident;
3. The patient is pregnant; or
4. The patient is a parent with custody or responsibility for the care and support of minor children.
   
   
6. Dispute Resolution
   If the withholding or withdrawing of life-sustaining intervention is in accordance with hospital policy on Medically Ineffective Intervention, but the patient/family member/surrogate decision-maker or significant other disagrees with the decision, the hospital Risk Manager or designee is contacted. Such disputes may be resolved by court order, if necessary.
1. In the event that there is a disagreement regarding the issuance of an order to withhold or withdraw life-sustaining intervention, the Hospital Bioethics Committee is available for consultation. The recommendations of the Committee are not binding in nature.
2. The Bioethics Committee may be accessed by:
1. Calling the Committee Chairperson directly or contacting the Medical Staff Office weekdays between 8:00 a.m. and 4:30 p.m. at extension 2707 to have the office assist in contacting the Chairperson.
2. Dialing "0" after 4:30 p.m. and on weekends to contact Nursing Supervision and request a Bioethics consultation.

Procedure

Care of the Dying Patient

Compassionate standards of care require that when the decision to withdraw life-sustaining intervention is made, consideration be given to alleviate any possible discomfort that the patient might endure.

1. Prior to the decision to withdraw life-sustaining a discussion between the physician, patient, and patient's family/surrogate with the support of Palliative Care, Social Services and Chaplain Services, will have occurred.
2. The physician and nurse will assess the patient for level of consciousness and existence of discomfort prior to the withdrawal of any life support measures.
1. Consideration will be given to:
1. The fact that the patient may experience pain or air hunger.
2. That the family may suffer if there is the perception that the patient is suffering.
2. A plan will be developed which may include medication, counseling, or both.
3. Medication will be given based on assessment of discomfort prior to the removal of life-sustaining intervention.
3. Upon withdrawal of vasoactive drugs, the nurse will re-evaluate the patient as indicated for the following:
1. Restlessness, anxiety
2. Increased heart rate and respiratory rate
3. Blood pressure changes
4. Respiratory distress, air hunger
5. Diaphoresis
4. The patient will receive medication for comfort based on the assessment of the above physiological parameters. Narcotics and anxiolytics can blunt perception of pain and make the patient more comfortable. Note: The development of respiratory depression and/or hypotension during the use of medication as outlined is NOT a reason to limit or discontinue medication if the patient continues to show signs and symptoms of distress.
5. Chaplain Services/Social Services are available to provide support for patient/family.