1. Definitions
1.1. Life Sustaining Treatments (LST) are medications or medical devices (also known as “life-support”) using mechanical or other artificial means to support or replace vital organ functions, either on a temporary or permanent basis for the purpose of sustaining organ function rather than restoring it. LSTs may include CPR, mechanical ventilation, artificial hydration, nutrition, hemodialysis and pharmacological or mechanical hemodynamic support.
1.2. Withdrawing of Active Life Sustaining Treatment (WDLST) is decision to actively stop a life-sustaining intervention presently being provided, often with the understanding that patient will most probably experience natural death from underlying disease or related complications.
1.3. Withholding Life Sustaining Treatment (WHLST) is decision not to start or increase life-sustaining interventions.
2. Ethical Aspects of Withholding or Withdrawing of Life Sustaining Treatment
2.1. Various professional societies agree that, where it has been decided that a treatment is not in the best interests of the patient, there is no ethical or legal obligation to provide it and there is no difference between WDLST and WHLST. Discussion should be framed based on “beneficence”, “non-maleficence”, “respect of autonomy” and “justice”.
2.2. Nepal medical council (NMC) agrees that “Where death is imminent, the medical practitioner should make sure that the patient dies with dignity and with as little pain and suffering as possible”.
2.3. “Administration of narcotics and sedatives titrated to alleviate pain and distress in a dying patient is not euthanasia but is palliative care which should be provided and clearly documented in the medical record”.
3. Legal Aspects of Withholding and Withdrawing Life Sustaining Treatment
In Nepal, withholding and withdrawing life sustaining treatment is guided by Nepal Medical Council Code of Ethics.
4. Withholding and Withdrawing Life Sustaining Treatment (Decision making considerations)
4.1. Using best clinical judgment, members of the health care team should determine whether LST have a reasonable chance of restoring the patient to a quality of life that he/she would find meaningful.
4.2. LST is not an “all or none” treatment plan. As such, an order to withhold CPR (Do not resuscitate or Do not intubate) should not necessarily exclude patients from receiving other appropriate LST, vasopressors and admission to ICU.
4.3. If it is not clear whether individual patients could recover to a meaningful quality of life, a trial of LST could be offered, but regularly reviewed for appropriateness.
4.4. There should be consensus among ICU team members about the options (including palliation) and the recommended plan before anyone approaches the patient or patient family regarding withholding or withdrawing life sustaining treatments.
4.5. It is important that ICU team maintain consistent communication with the patient/ family.
4.6. Good communication between the ICU team, patient, and family can enhance mutual trust and support, and reduce the possibility of disagreement or confusion.
4.7. It is important to recognize and address the influences of non-medical factors (cultural/religious/spiritual beliefs) in discussions concerning WDLST.
4.8. Documentation including names of those present, the content of the discussion, and the plan and timeline related to WDLST is of utmost importance and need to be performed regularly.
4.9. Discussions should be calm, honest, respectful, and compassionate. Patient and/or family should be explained in language they understand and make sure that they get the message right.
5. A respectful and dignified death
5.1. If decisions are made to withhold or withdraw LST, the goals of patient care in the ICU focus on comfort, and relief of suffering. The ICU team should provide a respectful, caring, and peaceful environment to best ensure a dignified death and a reverent family experience.
5.2. Palliative care services should be consulted whenever available.
6. Euthanasia
“Euthanasia is direct intentional killing of a person as part of the medical care being offered”. NSCCM and Nepal Medical Council, stands firmly against euthanasia. This practice is illegal in Nepal.
Further Readings:
1. Nepal Medical Council. Available at: https://nmc.org.np/files/4/Code%20of%20Ethics_Print_version.pdf (Accessed: March 21, 2023).
2. Bandrauk, N., Downar, J., & Paunovic, B. (2018). Withholding and withdrawing life-sustaining treatment: The Canadian Critical Care Society position paper. Can J Anaesth, 65(1), 105-122.
3. Treatment and care towards the end of life - General Medical Council. Available at: https://www.gmc-uk.org/-/media/documents/treatment-and-care-towards-the-end-of-life---english-1015_pdf-48902105.pdf (Accessed: March 21, 2023).
