1. { Withholding and Withdrawal of Life- Sustaining Medical Treatment Ethical and Legal Issues

2. On a regular basis providers are faced with the need to address the withholding or withdrawal of life-sustaining medical therapies. Ethical implications impact providers and families. Legal aspects influence decisions. What solutions exist for balance and dignity. The Issue 3. { The withholding or withdrawal of life- sustaining medical therapies is complex and presents many challenging ethical and legal issues for providers and families. Problem Statement 4. { Life-sustaining treatment serves to prolong life with out reversing the underlying condition. Life-sustaining treatments include mechanical ventilation, renal dialysis, chemotherapy, antibiotics, and artificial nutrition and hydration. American Medical Association, 1996 Patients can make their own decisions, surrogates can make decisions when the patient is unable, and a provider must always be honest and have the patients best interest in mind. Definition of Terms 5. { Achievement of fundamental goals regarding end of life is necessary to ensure protection for providers and patients. Legal Considerations 6. { Uniform Health-Care Decisions Act (UHCDA) of 1993. National policy, optional adoption by states. English, D. (2001) Legal Considerations 7. State of New Mexico Adopted Uniform Health Care Decision Act Provider protection Surrogates New Mexico Uniform Health-Care Decisions Act Legal Considerations 8. Legal Considerations Olsen, Swetz, & Mueller, 2010 9. { A providers commitment is to sustain life and relieve suffering. Ethical Dilemmas 10. Ethical Dilemmas The American Medical Association Policy for the Withholding and Withdrawing of Medical Treatment Providers must respect patient autonomy in decision making for their own care and treat their patients with dignity. American Medical Association, 1996 11. Hospice and Palliative Nurse Association Position Statement on the Withdrawal and Withholding of Life-Sustaining Therapies End of life choices are a quality of life issue. Hospice and Palliative Nurses Association, 2011 Ethical Dilemmas 12. Case Study #1 37 year old male, admitted with presumed CAP, intubated, then diagnosed with myocarditis and placed on ECMO. One week has passed without improvement. What now? 13. { {Ethical When does care become futile? Is the patient suffering? If he recovers, will it be the quality of life he wants? Legal Who makes his care decisions now? Is stopping medical therapy euthanasia? Case Study #1 14. { 91 year old male, history of dementia, bed bound in nursing home, infective process of unknown origin, on hospice. Family becomes emotionally distraught and request hospice revocation and all therapies short of intubation and CPR. Case Study #2 15. { {Ethical Is it in the patients best interest to pursue medical therapies? When does harm occur? Legal When can the provider refuse medical interventions? Is allowing the patient to die a crime? Case Study #2 16. There is no distinction between withholding and withdrawing life-sustaining therapies. Providers must have effective communication delivery with compassion and knowledge. Above all the dignity and autonomy of the patient must be paramount. Gwande, A., 2010 Summary 17. American Medical Association. (1996). Opinion 2.20-Withholding or withdrawing life- sustaining medical treatment. Retrieved from http://www.ama- assn.org/ama/pub/physician-resources/medical-ethics/code-medical- ethics/opinion220.page? English, D. (2001). The uniform health-care decisions act and it progress in the states. Retrieved from http://www.americanbar.org/publications/probate_property_magazine_home/rppt _ publications_magazine_2001_01mj_01mjenglish.html Gawande, A. (2010). Letting go. The New Yorker, 85, 36-42. Hospice and Palliative Nurses Association. (2011). HPNA position statement withholding and/or withdrawing life-sustaining therapies [PDF document]. Retrieved from https://www.hpna.org/DisplayPage.aspx?Title1=Position%20Statements New Mexico Uniform Health-Care Decisions Act, N.M. Stat. Ann. 24-7A-1 to 24- 7A-18 (1978, & 2011). Olsen, M., Swetz, K., & Mueller, P. (2010). Ethical decision making with end-of-life care: Palliative sedation and withholding or withdrawing life-sustaining treatments. Retrieved from http://www.mayoclinicproceedings.org/article/S0025-6196(11)60237- 1/fulltext#cesec9 References