Withholding/withdrawing life-

sustaining therapies

Suzana Makowski, MD MMM FACP

The EPEC™-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

Education in Palliative and End-of-life Care - Oncology

The

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EPEC-O

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Overall message

Withholding or withdrawing life-sustaining therapies is sometimes warranted, is ethical and legal in many circumstances.

Examples of life-sustaining therapies

Resuscitation

Intubation/mechanical ventillation

Blood transfusions

Dialysis

AICD

Antibiotics

Artificial hydration/nutrition

Hospitalization/ICU admissions

Surgery

Diagnostic tests

Let’s talk about food

Enteral Nutrition

NG, PEG, Jtube

Head & neck cancer,

Neurologic injury

Temporary loss of ability to eat.

Enteral Nutrition & Survival

No effect on: Aspiration risk Pneumonia risk Symptoms.

Associated with increased mortality in patients with dementia, etc.

Parenteral nutrition

Venous access

Beneficial with: long-term gi toxicity, short gut syndrome, ovarian carcinomatosis.

Not beneficial in: long-term feeding for cachexia/anorexia.

Effects of nutrition on survival & response rates

Odds ratio

Control 1.00

Survival 0.81p < 0.05

Tumor response 0.68

Parenteral hydration

IV or SQ

Does not relieve dry mouth

Common Concerns

Legally required to do everything?

Is withholding or withdrawing care euthanasia?

Are you (or the family) killing the patient by withholding or withdrawing nutrition, fluid, or life-sustaining treatment?

Steps to discuss withholding/withdrawing artificial

nutrition/hydration S – set-up, background

P – Preparation

I – Inquiry: what are the goals? What is the understanding? What cultural beliefs?

K – Knowledge: listen and share. Address misperceptions. (Not alleviate: dry mouth, decrease intake, fatigue/energy, starvation, urine output. Side effects: fluid overload, breathlessness, nausea/vomiting.)

E – Emotions: wait. Acknowledge. (starvation, giving up, suffering, “not doing something”)

S – Summarize/strategize

Cases

“We want to do what’s best, and what she wanted us to

do…”

CS is an 82 yo woman found unresponsive at home. Found to have large hemorrhagic stroke MCA, with only brainstem function remaining. PMH: HTN, high cholesterol.

Exam: Respirations shallow, rapid. HR fast. Unresponsive.

Brought “comfort one” form from refrigerator.

Niece is HCP. Agrees DNR/DNI no ICU. What is comfort care? Pt hasn’t eating in 3 days: doesn’t she need IVFluids, blood tests, oxygen tests?

“I don’t want her to starve”

89 yo patient with advanced Alzheimer’s dementia (speaks only a few intelligible words, dependent on all ADLs) admitted with dyspnea, cough, mental status change found to have aspiration pneumonia. Found to have aspiration pneumonia. Failed swallow evaluation.

Daughter/son knows patient doesn’t want pt to starve, but is concerned that pt can’t swallow. Additionally, nursing home might require feeding tube for readmission.

Thank you