Withholding and withdrawing medical interventions

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

Projec

t

EPEC-OTM

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

Survival0.81

p < 0.05

Tumor

response0.68

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