Termination of Life-Sustaining Treatment

Modern medical technology has made it possible to sustain the lives of people who have incurable medical conditions. The lives of patients who would otherwise die from irreversible illness within a foreseeable, but uncertain, time period can be prolonged by medical advancements and technological interventions that cannot cure their underlying terminal medical conditions. But who decides whether to use or withdraw these interventions?

When the question of whether to withhold or withdraw life-sustaining treatment from an individual who is incompetent or has no decision-making capacity arises, patients, physicians, families, surrogate decision makers, and healthcare institutions must face a myriad of confusing legal, ethical, and clinical issues. State statutes, court decisions, professional guidelines, accreditation standards, and federal Medicare regulations come to bear on end-of-life treatment decisions. Ethical principles are significant in all cases but are especially important in situations involving patients who have no written advance directives.

When agreement cannot be achieved among family members regarding the patient's course of care, surrogate decision makers, physicians, and hospital institutional ethics committees may offer guidance. If such intervention is not implemented or if it fails to produce accord, the parties may be required to call upon the courts to decide on the issue of withholding or withdrawing life-sustaining treatment from a patient whose wishes are not documented in an advance directive. Before court intervention, risk managers may be called upon to facilitate the processes and steps necessary to assist patients, families, and staff members.

Despite the intense media attention that was focused on the case of Terri Schiavo, a Florida woman who died in 2005 after a prolonged and contentious legal battle concerning withdrawal of her feeding tube, many Americans remain without written advance directives. Consequently, challenging ethical and clinical issues surrounding the care of patients with terminal illnesses will continue to arise and require resolution. Facilities may benefit from the resources and assistance that risk managers, who have experience in approaching difficult patient care issues with empathy and compassion, may provide in addressing these dilemmas. Knowledgeable risk managers can facilitate consultations with ethics experts and legal counsel, when appropriate, to foster resolution of disagreements among patients, their families, and treating physicians over end-of-life care issues. A comprehensive discussion of the complex and controversial issues surrounding the subject of terminating life-supporting treatment could fill many volumes. This Risk Analysis examines several headline-grabbing cases and the issues they have brought to light and focuses on the major legal, ethical, clinical, and risk management issues that may arise concerning withholding and withdrawing life-sustaining interventions. This Risk Analysis also provides a framework to guide the development of institutional policies and procedures and training for healthcare providers involved in end-of-life care. A glossary of relevant legal terms and concepts is provided. The following...