[MUSIC] Withdrawal of treatment is a challenging and emotive issue. It is influenced by many factors: the patient's prognosis, values and treatment preferences, cultural and religious beliefs, the families and the doctor's beliefs and practices as well as the resources available. It is important to stress that withdrawal of treatment is not withdrawal of care. The care of the patient is never abandoned by the healthcare team. We always begin with the intent to make the patient better and interventions can be justified on this basis. But we must be able to reevaluate our treatment goals when expected outcomes are not achieved. The decision to withdraw treatment marks a point in the process of medical therapy with the primary focus is adjusted from saving the patients life to making their last moments as comfortable as possible. The benefits of modern medical therapies, such as cardiopulmonary resuscitation, renal dialysis, mechanical ventilation, nutrition and hydration, are considerable. However, life has a natural end. And the use of such supportive treatments can in, certain cases, sustain life artificially in patients for whom there is little or no hope of recovery. It is not in the best interests of a patient to start or continue such treatments if we cannot restore them to a quality of life they would find acceptable. The doctor's responsibility is not to supply every single type of treatment to a patient, but rather to always to provide appropriate care. Recognizing the limits of medical therapy is part of that key. We do not want to be complicit in prolonging suffering in the dying process in any patient. Arriving at the point where ongoing therapy is futile occurs commonly. In the United States of America 38% of deaths in intensive care units involve active withdrawal of treatment, and a further 10% entail withholding treatment. Defining futility is difficult. The term non-beneficial is preferable to futile as the crux of the matter is whether or not a treatment is able to help the patient. Let me give you an example from my own ICU practice. We have the capability to place patients on venoarterial extracarpurial membrane oxygenation - VA-ECMO. This entails placing a large pipe into a central vein to drain blood, as well as a large pipe into an artery to return it. When the pump achieves adequate flow rate, we are able to completely support a patient who has a non-functional heart and lungs. It is essentially cardiopulmonary bypass run in the ICU. It is physiologically possible to do this for almost every patient. But we don't do VA-ECMO for every patient because the ECMO team has to make a judgement call about whether there is a potential benefit. Such an intervention is extremely invasive, expensive, and needs to be justified by a reasonable chance of a successful outcome. VA-ECMO is a particularly high tech example of organ support. But the same argument can be made for any treatment offering a patient no reasonable chance of recovery. Be it mechanical ventilation, ionotropic support, artificial nutrition, intravenous fluids, or even antibiotics. All can artificially and inappropriately prolong life. Many clinicians feel that it is easier not to start or withhold a treatment than to stop or withdraw it. While there is a natural tendency to believe this, there is no ethical distinction between the two. This is supported legally where in numerous cases, the courts have found that it is equally justifiable to actively withdraw as to passively withhold non beneficial life sustaining treatments. Withdrawing or withholding treatment is not euthanasia. It is a decision that recognizes the limits of medical therapy, and allows a person to progress on their natural course. Euthanasia actively seeks to end the patient's life. It is illegal in South Africa and most countries. Removing mechanic ventilation from a patient and giving opioids such as morphine can feel like very direct actions, but when the intent is to secure comfort they are appropriate. Leaving a patient on ventilator in such a situation and waiting for the patient to die from another cause such as bedsores or recurrent pneumonias is like saying we'll let nature take a course and ignore the consequences of our interventions. Opiates are the mainstay of palliative medicine. They can be titrated to relieve unpleasant symptoms, such as dyspnea and pain, to whatever dose is required by the patient. There is no maximum dose. Sedation over and above what the patient needs to be comfortable, is however unacceptable. Families may ask, please can we just get this over with? As long as there is no evidence of suffering or discomfort, that is as far as the doctor is allowed to go. It is often seen as easier to not make a decision and let things be than to intervene. But inaction is itself a form of action and may directly cause suffering. For example, leaving a patient on high doses of medication, such as an adrenaline infusion as the only option to maintain the blood pressure is obviously inappropriate when it is causing complete gut and limb ischemia. Withdrawing the adrenaline is the more humane course of action, even if this results is the imminent demise of the patient. The intent is to prevent suffering. DNRs, Do Not Resuscitate orders are an effective way to prevent inappropriate treatments at the end of life. These formally recognized but uncertain situations, all therapeutic options have been explored, and further escalation of treatment is inappropriate. Attempting CPR on a patient with no treatment options available or when they have expressed a wish not to be resuscitated, is wrong. These situations can commonly be anticipated and where possible, advanced directives should be sought. Critically ill patients often lack the capacity to participate in decision-making regarding their treatment. In cases where the patient is unable to make decisions a surrogate decision maker usually the next kin is asked to make decisions on the patient's behalf. The focus on end of life treatment decisions making should be focused on joint decisions making. The doctor brings medical experience to discussion and the family represents the patient opinion on the expected outcome which medical treatments can offer. There is a common misperception that unlimited resources can overcome any medical condition. The financial cost of intensive care therapy is high. A lack of funds should not be the precipitating event for a discussion about prognosis, but rather the clinical situation. To recap, there is no ethical or legal difference between withdrawing or withholding treatment. Withdrawal of non-beneficial treatment is not euthanasia. It allows a patient to die with dignity and as little discomfort as possible. When treatment options have been exhausted and there is no hope of meaningful recovery. Finally, I must emphasize again that it is only nonbeneficial treatments which are withdrawn, never the care of the patient. [MUSIC]
