Termination of Life Support

Indications

Ethical and Practical Considerations When Terminating Life-Sustaining Treatment

Contemporary medical ethics distinguishes between withdrawing life-sustaining treatments, which may indirectly or unintentionally hasten death, and administering interventions specifically intended to expedite death. This nuanced understanding highlights the importance of prioritizing patient comfort and dignity in end-of-life care.

Early and Compassionate Communication

Physicians caring for severely ill patients, whether in a hospital or clinical setting, should consistently consider the need for comfort measures and end-of-life discussions. This proactive approach is especially crucial when treating patients with multiple organ failure, advanced-stage cancer, neurodegenerative diseases, or those requiring mechanical ventilation.

Open communication about the "goals of care" and end-of-life preferences is essential for patients facing a terminal illness, especially those with a life expectancy of 30 days or less. This delicate conversation requires sensitivity, empathy, and cultural awareness. The goal is to provide honest information with realistic expectations while preserving a sense of hope.[7] 

Engaging with Surrogate Decision-Makers

When direct communication with patients is not feasible due to their clinical condition, discussions should be conducted with their legal surrogate decision-maker. In complex situations, confirming the surrogate's legal status is crucial before proceeding with significant medical discussions. Appointing a single healthcare team member as the primary point of contact fosters trust and ensures continuity of care.[8]

Prioritizing Comfort and Dignity

The primary objective of end-of-life care is to identify and alleviate physical and psychological symptoms while mitigating emotional and spiritual distress.[9] Communication strategies, such as the British SAGE & THYME model and the Australian PREPARED guidelines, can help clinicians navigate these challenging conversations more comfortably and effectively.[10][11]

Examples of Life-Sustaining Treatments

Life-sustaining treatments encompass a range of interventions, including:

• Mechanical ventilation
• Renal dialysis
• Vasoactive medications
• Chemotherapy
• Antibiotics
• Insulin
• Artificial nutrition and hydration

Decisions regarding withholding these treatments should be made collaboratively with the patient or their surrogate, considering their values, preferences, and overall prognosis.

Contraindications

Ideally, discussions about end-of-life care should involve the patient directly. However, it is important to gauge the patient's receptivity to such conversations first. If the patient is experiencing anxiety or stress, it may be necessary to temporarily postpone the discussion, allowing them time for emotional processing and support.

Patients with cognitive impairment due to an acute or chronic condition may lack the capacity to engage in meaningful discussions about their goals of care. In these cases, it is essential to contact the legal surrogate decision-maker to ensure that the patient's best interests and previously expressed wishes are represented in the decision-making process.

Personnel

The following personnel are key to providing comfort measures for patients with terminal illness:

• The patient's family members
• The treating physician or consultant
• Nurses (inpatient, home health, or hospice)
• Social workers
• A care manager or administrative staff assisting with hospice placement, home hospice arrangements, or coordinating financial resources for comfort care
• Physicians from related fields, such as palliative, pain, and hospice medicine specialists, who can assist the process
• The clinical pharmacist, especially in the inpatient setting
• A nurse educator
• A spiritual staff or chaplaincy

Optional personnel include:

• Complementary medicine practitioners
• Music therapists
• Aromatherapists

Preparation

Planning and Implementing the Transition to Comfort Care

Meetings with the patient or their family should be thoughtfully planned, ideally including key personnel such as physicians, nurses, social workers, and palliative care specialists. This collaborative approach ensures comprehensive support and fosters open communication.

Empathetic Communication and Shared Decision-Making

Discussions about potential life support termination should be approached with empathy and compassion, emphasizing the importance of understanding the patient's preferences—either directly or through their legal surrogate. The patient's clinical condition, management plan, anticipated course, and prognosis must be communicated in clear, non-technical language. Care levels should be outlined and adjusted according to the patient or surrogate's wishes. To ensure understanding, the surrogate should be encouraged to summarize the main points of the conversation.

Preparing for the Dying Process

Family members should be informed about the physical changes that may occur as the patient transitions to comfort care, including changes in appearance, breathing patterns, and bodily functions. The palliative care team plays a crucial role in providing guidance and support during these sensitive conversations.[12]

Comprehensive End-of-Life Planning

A multidisciplinary plan involving social workers, primary care physicians, and hospice providers should be developed if the patient’s life expectancy extends beyond a few days. Children in the family should be informed of the impending death in an age-appropriate, sensitive manner, with guidance from child-care specialists. Religious or spiritual support can be provided by clergy or chaplains to offer comfort and solace to the patient and family. If appropriate, discussions about organ donation and autopsy should also occur. The organ transplant team must lead detailed conversations about organ donation to avoid any conflicts of interest.

Establishing Code Status and Comfort Care Measures

After discussing the overall plan, the patient's code status should be established, clarifying their preferences for resuscitation and intubation. A "no escalation of care" plan may be implemented if the patient's condition deteriorates. The family should be informed of the specific steps in withdrawing life support, including discontinuation of routine diagnostic interventions, initiation of medications for pain and symptom management, and removal of invasive lines and tubes. Typically, one intravenous line and a bladder-draining catheter are maintained to administer pain and symptom control medications, including antiepileptic drugs if required.

Framing the transition as the "initiation of comfort care" rather than the "withdrawal" or "termination of life support" can be beneficial. This language emphasizes the shift in focus toward maximizing patient comfort and dignity in their final days.

Timeline and Family Accommodations

A tentative timeline for palliative extubation and cessation of life-sustaining treatments should be planned, allowing reasonable accommodations for family members traveling from afar. Institutional visitor policies may need to be adjusted to permit extended family presence while respecting the privacy of all patients and their families. Nonpharmacological comfort measures, such as religious prayers, music, and aromatherapy, may also be offered to provide solace to grieving family members.

Ethical Considerations in Decision-Making

Decisions about initiating, continuing, or withdrawing life-sustaining treatment require careful consideration of the benefits and burdens of therapy in relation to the patient's or surrogate's preferences and goals. The ethical decision to remove life support is complicated but revolves around the principles of beneficence, nonmaleficence, and patient autonomy. Life-sustaining treatments are not obligatory when the burdens outweigh the benefits or when the goals of care shift from extending life to prioritizing comfort and quality of life. A time-limited trial, with the option to discontinue if the desired outcome is not achieved, may be considered when the risk-benefit ratio of a treatment is uncertain. Ultimately, the decision to withdraw life-sustaining treatment is ethically permissible if it aligns with the patient’s goals of care, even if it may result in death.

Many jurisdictions have laws governing the removal of life support, though most protect the patient's right to refuse medical treatment. The process of removing life support may be governed by specific laws that include requirements for documentation or, in some cases, court rulings. Healthcare providers follow institutional policies and procedures to ensure ethical and legal compliance in end-of-life care decisions.

Emerging Concepts in the Termination of Life Support

Several new concepts, as mentioned below, have emerged in discussions about the termination of life support, reflecting evolving societal perspectives and medical advancements.

Medical Aid in Dying

The procedure of medical aid in dying (MAID) involves providing a terminally ill patient with a lethal dose of medication for self-administration, allowing them to end their life with dignity. MAID differs from euthanasia, as it requires the patient to self-administer the medication. The concept's legality and eligibility criteria vary by jurisdiction.[13] While sometimes referred to as "physician-assisted suicide" or "physician-assisted dying," "MAID" is generally considered the preferred term.

Physician Orders for Life-Sustaining Treatment

Physician orders for life-sustaining treatment (POLST) forms are designed to communicate a patient's preferences for life-sustaining treatments in emergencies. These forms are more specific and actionable than advance directives, ensuring that the patient's wishes are honored across different care settings.[14] While POLST forms are useful in emergencies, they cannot substitute for comprehensive, advanced care planning.

Shared Decision-Making

This collaborative approach involves healthcare providers, patients, and families working together to make informed treatment decisions. It incorporates the patient’s values and preferences into the decision-making process, aiming to create a care plan that aligns with the patient’s goals.

Compassionate Extubation

This process involves withdrawing mechanical ventilation from a patient nearing the end of life or who has chosen to stop life-sustaining treatments. The focus is on ensuring comfort and preserving dignity throughout the dying process.

Advanced Care Planning

This process involves discussions and documentation between patients, families, and healthcare providers regarding preferences for future healthcare, including end-of-life care. Advanced care planning aims to prepare for potential future health scenarios and ensure that the patient’s wishes are known and respected.

Goal-Concordant Care

This approach ensures that medical interventions align with a patient's personal goals and values. Goal-concordant care emphasizes patient-centered therapy and aims to provide treatments that are consistent with the patient’s preferences and desired quality of life.

Futile Care Theory

This theory posits that medical treatments failing to achieve their intended goals or provide meaningful benefits to the patient may be considered futile and ethically withdrawn. This concept helps guide decisions on whether to continue or discontinue specific interventions. However, the definition of "futility" can be subjective and may lead to controversy.

Dignity Therapy

This therapeutic approach assists patients with terminal illnesses in finding meaning and leaving a legacy by creating a document that captures their life stories, values, and messages for loved ones. The intervention aims to enhance patients' sense of dignity and provide closure.

Technique or Treatment

Comfort care begins at the patient’s chosen time and place, with their preferred individuals present. The process typically involves administering pain medication, usually an opioid, along with an anxiolytic, often a benzodiazepine.[15] This infusion is followed by palliative extubation, accompanied by symptom control medications to manage anxiety, nausea, vomiting, dyspnea, air hunger, oral and endotracheal secretions, and fever. Artificial tears and oral hygiene measures are also provided. Depending on the patient’s preference, care should balance effective pain control with maintaining wakefulness. Comfort feeding and supplemental oxygen may also be offered.[16] 

Family members are encouraged to spend time with the patient, and efforts are made to minimize nursing interventions. They are also invited to participate in legacy-building activities, such as taking pictures or making handprints with the patient if possible.[17] If the patient survives longer than expected, they may be transitioned to inpatient or home hospice care with appropriate support. A healthcare team member should confirm the time of death, complete the death certificate, and handle any related documentation. Reaching out to the grieving family to offer condolences is a compassionate practice. Additionally, medical staff should address and alleviate their own moral and emotional stress from these clinical encounters. Informal and formal measures, such as counseling, can help manage this distress, as neglecting it may lead to empathy fatigue and burnout.

Clinical Significance

Terminating life support is sometimes clinically necessary for patients at the end of life who have expressed a desire to avoid aggressive interventions in case their clinical condition deteriorates. Life support termination prevents futile care that may involve invasive interventions, which can potentially and adversely impact the patient's quality of life without offering significant survival benefits. Withdrawing life-sustaining treatment also provides comfort to the grieving family, allowing them to witness a pain-free and peaceful death of their loved one.

Enhancing Healthcare Team Outcomes

A multidisciplinary approach is essential for humanely and effectively implementing life support termination. Compassion, empathetic communication, and support staff involvement help families address social and financial challenges. Together, these steps ensure the delivery of high-quality care to patients with terminal illnesses. Palliative care has been shown to improve quality of life and, in some cases, even extend life expectancy.[18] Terminating life support, with a focus on effective pain and symptom management, allows the patient to die peacefully. This process also supports grieving family members, helping them cope with their distress and bereavement. 

Death is the ultimate reality for everyone. While modern medicine can delay death to some extent, it is essential to ensure that the dying process is pain-free for the patient and less stressful for the grieving family when death is inevitable. A physician's duty extends beyond immediate patient care to include support for the family both before and after bereavement. While everyone aspires to a good life, providing access to a "good death" is equally important when possible.