Canada’s critical care doctors are confronting one of the most sensitive issues in end-of-life care: Once the agonizing decision has been made to remove someone from life support, what’s the most appropriate way to do so?
The first national guidelines are under development on the best way to withdraw life support in patients expected to die.
The goal is to set standards for care, support grieving families and minimize the patient’s pain or distress while they’re dying, but still alive.
But while numerous guidelines exist around deciding when to stop life-sustaining treatments, there’s little to guide doctors on the actual withdrawal of life support — including how to avoid doing anything that could be construed as hastening or speeding death.
“There isn’t a lot of evidence around the ideal way to do this,” says Dr. James Downar, a critical care and palliative care doctor at the Toronto General Hospital who is helping develop the guidelines with the Canadian Critical Care Society.
“There’s no way you could ever get the best possible evidence for this type of thing, because the best possible evidence would be if we could interview the patients once they have died, and ask, ‘How did it go? What was the quality?’ ” says Downar.
According to Downar, only a handful of Canadian intensive care units use a formal protocol when withdrawing life support.
Ten to 30 per cent of people who die in hospital die in intensive care units.
The vast majority of ICU deaths occur through the withdrawal of life support, in most cases, a ventilator or breathing machine.
When ventilation is discontinued, the person’s oxygen level falls while carbon dioxide rises. “Eventually their heart will stop and they will die,” Downar says.
Death often takes 30 or 40 minutes but it could be almost immediate – or many days later.
“There are many people who want to take away everything as quickly as possible so that the person can die without a tube or anything in them,” Downar said.
The other approach is to go slowly, dialing down the settings and slowly weaning the patient off ventilation. In Japan, it’s known as the “soft landing,” Downar says — “don’t do anything sudden so that nothing looks as if it caused the death of the patient.”
ICU teams look for signs of distress — for example, “air hunger” or shortness of breath, sweating, grimacing or grunting. “Those are all fairly reliable signs that someone is short of breath or in pain,” Downar said.
But also controversial is whether doctors should wait for symptoms before starting sedatives and pain medication, or treat the patient anyway.
“If we make a mistake in end-of-life care, it’s that we undertreat symptoms,” Downar said.
“I don’t think anybody could ever tell you how much pain medication someone should receive as they die,” Downar said. “But, we undertreat symptoms because of this fear that opioids are inherently harmful and that giving opioids might shorten life.”
Downar says no evidence exists that morphine and other opioids used to control pain speed death.
What’s more, doctors are protected by what is known as the doctrine of “double effect,” which distinguishes between giving medication with the intent to end the person’s life, and giving medication to ease suffering.
“As long as your intent is comfort, it’s legal,” Downar said.
Ultimately, the goal is to ensure “that patients are appropriately managed during the final state of their life as we withdraw life support,” said Dr. Claudio Martin, president of the Canadian Critical Care Society.
“We also want to minimize any moral or ethical, or any other form of distress that the health care team at the bedside might have,” he said.
“It’s never easy for anybody to go through that process. You want to make sure everybody is comfortable with the way it’s being done.”
(By Sharon Kirkey)