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Invited commentary: The decision to withdraw treatmentand its optimal method are not mutually exclusive
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Letters to the Editor
Invited commentary: The decision to withdraw treatment and its optimal method are not mutually exclusiveB We thank Saralegui et al for their interest in our work [1] and additionally providing us an insight on the “withdrawal of treatment” issue from a Spanish perspective. They make 2 important points that require attention and clarification. First, they state that “the key decision lies in whether to forego life-sustaining-treatment or to maintain care, and not in the procedure to be followed.” Although we do agree that the decision to withdraw treatment remains the most important and challenging question in the care of any patient, our published work [1] focused primarily on addressing the approach to withdrawing treatment only after such a decision has been made. It is important to clarify that there exist 2 very separate components to this difficult clinical scenario of a “hopelessly ill patient.” Initially, a full assessment of reversibility and potential for recovery must be performed and forms the basis of any treatment withdrawal decision. If any potential for improvement exists, all life-prolonging measures must be used to give the patient the best chance of recovery. If no potential for recovery exists, treatment withdrawal can be considered on the basis of quality-of-life assessment, patient comfort, family wishes, and multidisciplinary input. It is here that a dearth of guidance for clinicians exists both nationally and/or internationally, making this already difficult scenario all the more challenging, particularly in younger or brain-injured patients. It is only once a decision to withdraw treatment has been made can the medical multidisciplinary team and family move to considering the best approach to withdrawal of treatment: extubation or tracheostomy formation, the main focus of our published work [1]. We would advocate that a framework and guidelines be made available to clinicians and their teams, as is the case in Spain reported by Saralegui and colleagues. Therefore, we feel that both questions—whether to withdraw treatment and the optimal procedure to be followed thereafter—are not mutually exclusive. Therefore, importance cannot and should not be placed on one over the other because both require careful and practical consideration for the patients, relatives and medical staff involved. Second, Saralegui and colleagues state and quote a specific reference indicating that “the counseling of physicians is not always the most appropriate” for families or patient surrogates during withdrawal of life support decisions [2]. The quoted study, conducted by White et al [2], aimed to understand the attitudes of surrogate decision makers toward receiving a physician's recommendation during deliberations about whether to limit life support for an incapacitated patient. A prospective, mixed methods study was conducted among 169 surrogate decision makers for critically ill patients. Surrogates sequentially viewed 2 videos of simulated physician-surrogate discussions about whether to limit life support, which varied only by whether ☆
Disclosure: The authors report no conflicts of interest.
the physician gave a recommendation. The main quantitative outcome of interest was whether surrogates preferred to receive a physician's recommendation in this setting. The authors interestingly reported that 56% (n = 95) of patient surrogates preferred receiving a physician's recommendation during a withdrawal of support decision, 42% (n = 70) preferred no recommendation, and 2% (n = 4) did not indicate a specific preference. Although the authors of this study conclude that no clear consensus was reached among surrogates about whether physicians should routinely provide a recommendation in this setting, we believe that although patient families are central and should be involved in the decision-making process [3], physicians should drive such decisions, as indicated by British Medical Association guidance [4]. In the American setting, where this study was conducted, a significant number (more than one half) of the surrogates in the study did clearly want a physician's input. Therefore, we would be strongly supportive of a key role for the physician during this difficult time and challenging decision making for families, relatives, and the multidisciplinary team during withdrawal of treatment. Sanjay Haresh Chotirmall MB, MRCPI, MRCP(UK) Noel Gerard McElvaney MB, FRCPI, FRCPC Department of Medicine Royal College of Surgeons Dublin 9, Republic of Ireland Respiratory Research Division Department of Medicine Education & Research Centre Beaumont Hospital Dublin 9, Republic of Ireland E-mail address: [email protected] Amandeep Kaur Mann MB Department of Medicine Royal College of Surgeons Dublin 9, Republic of Ireland doi:10.1016/j.jcrc.2010.07.003
References [1] Chotirmall SH, Flynn MG, Donegan CF, et al. Extubation versus tracheostomy in withdrawal of treatment-ethical, clinical, and legal perspectives. J Crit Care 2010;25(2):360.e1-8 [Epub 2009 Oct 21]. [2] White DB, Evans LR, Bautista CA, et al. Are physicians' recommendations to limit life support beneficial or burdensome? Bringing empirical data to the debate. Am J Respir Crit Care Med 2009;180(4):320-5 [Epub 2009 Jun 4]. [3] Keenan SP, Busche KD, Chen LM, et al. A retrospective review of a large cohort of patients undergoing the process of withholding or withdrawal of life support. Crit Care Med 1997;25:1324-31. [4] Withholding and withdrawing life-prolonging medical treatment. Guidance for Decision-Making. British Medical Association. Blackwell Publishing – 3rd ed. January 16 2007.
Letters to the Editor
Invited commentary: The decision to withdraw treatment and its optimal method are not mutually exclusiveB We thank Saralegui et al for their interest in our work [1] and additionally providing us an insight on the “withdrawal of treatment” issue from a Spanish perspective. They make 2 important points that require attention and clarification. First, they state that “the key decision lies in whether to forego life-sustaining-treatment or to maintain care, and not in the procedure to be followed.” Although we do agree that the decision to withdraw treatment remains the most important and challenging question in the care of any patient, our published work [1] focused primarily on addressing the approach to withdrawing treatment only after such a decision has been made. It is important to clarify that there exist 2 very separate components to this difficult clinical scenario of a “hopelessly ill patient.” Initially, a full assessment of reversibility and potential for recovery must be performed and forms the basis of any treatment withdrawal decision. If any potential for improvement exists, all life-prolonging measures must be used to give the patient the best chance of recovery. If no potential for recovery exists, treatment withdrawal can be considered on the basis of quality-of-life assessment, patient comfort, family wishes, and multidisciplinary input. It is here that a dearth of guidance for clinicians exists both nationally and/or internationally, making this already difficult scenario all the more challenging, particularly in younger or brain-injured patients. It is only once a decision to withdraw treatment has been made can the medical multidisciplinary team and family move to considering the best approach to withdrawal of treatment: extubation or tracheostomy formation, the main focus of our published work [1]. We would advocate that a framework and guidelines be made available to clinicians and their teams, as is the case in Spain reported by Saralegui and colleagues. Therefore, we feel that both questions—whether to withdraw treatment and the optimal procedure to be followed thereafter—are not mutually exclusive. Therefore, importance cannot and should not be placed on one over the other because both require careful and practical consideration for the patients, relatives and medical staff involved. Second, Saralegui and colleagues state and quote a specific reference indicating that “the counseling of physicians is not always the most appropriate” for families or patient surrogates during withdrawal of life support decisions [2]. The quoted study, conducted by White et al [2], aimed to understand the attitudes of surrogate decision makers toward receiving a physician's recommendation during deliberations about whether to limit life support for an incapacitated patient. A prospective, mixed methods study was conducted among 169 surrogate decision makers for critically ill patients. Surrogates sequentially viewed 2 videos of simulated physician-surrogate discussions about whether to limit life support, which varied only by whether ☆
Disclosure: The authors report no conflicts of interest.
the physician gave a recommendation. The main quantitative outcome of interest was whether surrogates preferred to receive a physician's recommendation in this setting. The authors interestingly reported that 56% (n = 95) of patient surrogates preferred receiving a physician's recommendation during a withdrawal of support decision, 42% (n = 70) preferred no recommendation, and 2% (n = 4) did not indicate a specific preference. Although the authors of this study conclude that no clear consensus was reached among surrogates about whether physicians should routinely provide a recommendation in this setting, we believe that although patient families are central and should be involved in the decision-making process [3], physicians should drive such decisions, as indicated by British Medical Association guidance [4]. In the American setting, where this study was conducted, a significant number (more than one half) of the surrogates in the study did clearly want a physician's input. Therefore, we would be strongly supportive of a key role for the physician during this difficult time and challenging decision making for families, relatives, and the multidisciplinary team during withdrawal of treatment. Sanjay Haresh Chotirmall MB, MRCPI, MRCP(UK) Noel Gerard McElvaney MB, FRCPI, FRCPC Department of Medicine Royal College of Surgeons Dublin 9, Republic of Ireland Respiratory Research Division Department of Medicine Education & Research Centre Beaumont Hospital Dublin 9, Republic of Ireland E-mail address: [email protected] Amandeep Kaur Mann MB Department of Medicine Royal College of Surgeons Dublin 9, Republic of Ireland doi:10.1016/j.jcrc.2010.07.003
References [1] Chotirmall SH, Flynn MG, Donegan CF, et al. Extubation versus tracheostomy in withdrawal of treatment-ethical, clinical, and legal perspectives. J Crit Care 2010;25(2):360.e1-8 [Epub 2009 Oct 21]. [2] White DB, Evans LR, Bautista CA, et al. Are physicians' recommendations to limit life support beneficial or burdensome? Bringing empirical data to the debate. Am J Respir Crit Care Med 2009;180(4):320-5 [Epub 2009 Jun 4]. [3] Keenan SP, Busche KD, Chen LM, et al. A retrospective review of a large cohort of patients undergoing the process of withholding or withdrawal of life support. Crit Care Med 1997;25:1324-31. [4] Withholding and withdrawing life-prolonging medical treatment. Guidance for Decision-Making. British Medical Association. Blackwell Publishing – 3rd ed. January 16 2007.