The high percentage of death in intensive care unit is always attributed to the withdrawal of life support machine. In Australia, research shows that a significant proportion of deaths that occurred in the intensive care unit preceded a decision supporting the withdrawal of the life support and this is a case in many countries across the globe including Australia. Withdrawal of life support refers to the process of discontinuing critical care treatment for a patient who is terminally ill, and the decision can be made by the family, government or doctor (Way, Anthony, & Curtis, 2002). The family can make the decision after discussions with the doctor when there is no hope for the patient even if they continue using the life support methods.
The government decision is a legal one, and it is arrived at after disagreement with family members for the best interests of the patients in a situation called "government knows best." The medical personnel can reach the decision to discontinue the life support in what is known as "doctor knows best." However, the concept of withdrawal of life support in Australia has many legal and ethical aspects, for instance, the family suing the doctor or government in a case where they did not want the withdrawal of life support withdrew (Willmott, White, Smith , & Wilkinson, 2014 ). Ethical issues arise due to some religious organizations questioning the wisdom of extending life through a machine or whether withdrawing the life support amounts to killing.
The process of withdrawing life support can be a challenging affair not only for the doctors but for patients and family members as well. The common moral occurrence when the life of the patient seems to be in danger is to do anything possible in the power of the family or doctor to save such a patient. Some of the interventions tried can include trying new interventions, trying all manner of treatments, conducting experiments and any other response that is thought to save such a patient. Many of the arguments regarding life support equipment's take a legal and ethical perspective, with the main argument being whether to initiate a life support processor or forgo it and let nature take its course (Centre for Healthcare Improvement, 2015). Such a process becomes a big dilemma such that most doctors and families mostly opt to withhold the life support instead of trying it and later having to withdrawal it, an action which can result in a legal case.
Ethical Considerations based on Deontology and Consequentialism Theories
The ethical considerations followed when withdrawing life support include deciding whether a fatal pathology is present in the body of the patient, whether resisting the fatal pathology involves effective or ineffective therapy. Moreover, there is a consideration of whether the effectiveness of the therapy imposes an excessive burden and lastly knowing the key intentions of the people removing the life support. The existence of fatal pathology is always the first concern which is considered when deciding the use or withdrawal of life support from a patient (Gedge, Giacomini, & Cook, 2007). In medical terms, a fatal pathology refers to a condition, illness or disease which has the capability of causing or resulting in the death of a person. Some of the fatal pathologies may include accidents, cancer, diabetes, aids and other end-stage renal diseases.
Deontological ethics is the ethical position which is undertaken to judge the morality of an action based on the existing rules and just not what people think. The concept of deontology suggests that some acts are morally obligatory regardless of what the results are for human welfare. For instance, withdrawal of life support could be done simply because the doctor advised such an action. A physician in a healthcare facility is assumed to know every detail and thus whatever decision they make, it is supposed to be followed. This shows that even though the action might hurt the family members, the action is taken based on the rules.
During such times doctors ask themselves a lot of ethical questions such as should attempts be made to remove, circumvent or alleviate the disease or illness through medical therapy or should the doctors allow nature to take its course. In this context, letting nature take its course means letting the person die from the existing pathology instead of interfering with it. Some diseases and illnesses which involve such considerations mainly result to death in the long run, and thus decisions can be made to let the patient die instead of interfering with a natural process. For instance, should diabetes be circumvented through the use of insulin, should aids be circumvented through the use of ARVs or should attempts be made to remove cancer from the body through surgery or chemotherapy?
Consequentialism is a concept that states that an action taken is judged solely by the results it brings. For instance, the withdrawal of life support can be advised in the case where the family members will incur heavy costs and yet the patient will not recover. Moreover, the doctors might see that the patient is suffering more when on life support machine and yet there is no hope and thus decide to withdraw it. However, the other aspect entails the loss of life and from a consequenialist approach there is a balance that one must achieve in determining the best outcome of a decision.
This argument has both critics and supporters, with medical personnel and many people proposing the interventions to save lives while some religious leaders oppose the move of putting people on a life support. The proposers argue that medical technologies should be used to combat fatal pathologies by mean of medical therapy since the process helps in saving lives. Interestingly, the discussion changes when it comes to withdrawing life support where both the critics and supporters term is as murder since if the patient is alive, removing the life support would terminate the patient's life. Most physicians always opt to withhold life support if they sense that the patient has no chance of making it out alive (Willmott, White, Smith, & Wilkinson, 2014 ). Such a move is meant to avoid making the ethical decision as for whether to withdraw the life support machine and let the patient die.
Gedge, Giacomini, & Cook (2007) argues the right of a person refusing medical intervention is well articulated and established but it has remained unclear on the best approaches that need to be adopted to protect such rights when a person is on life support machines. The existing ethical guidelines do not provide a clear advice on what need to be done, which is largely attributed to the moral equivalence that is associated with the withdrawal of such life supporting machines. In numerous cases that involve the withdrawal of life support machine, tere is aperception that doctors normally wthhold information relating to the interventions that can be done on a patient necessarily judged futile based on the condition of the patient (Aitken, Marshall, & Chaboyer, 2016). As such, one can argue that doctor posses the greater power in the decision making process concerning whether to withdraw the life support machines as compared to the affected patients or proxies.
The decision to put a patient on life support is reached by the argument that preserving a life through medical therapy enables the patient to strive for the important goods in life. In medical terms, the necessary goods in life include preservation of life, the pursuit of the truth, taking care and loving our families and formation of communities with other people. But another question arises; is a terminally ill patient capable of striving for the goods in life? In most cases, extending the life of the patient through life support or medical therapy does not enable the patient to strive for the ideals of life (Gedge, Giacomini, & Cook, 2007). Even if failing to withdraw the life support does enable striving for goods of life, it may in turn place a burden on the patient making it hard.
For instance, in the event where the death of the patient is imminent and unavoidable, failing to withdraw the life support can just lead to a burden since there is no chance of the patient recovering. A good example of this case is a patient who depends on a respiratory machine to breathe since they are severely debilitated due to pathologies in many organs. Such a patient may request the removal of the respirator because even living in that condition cannot allow her to pursue any of the goods in life (Willmott, White, Smith , & Wilkinson, 2014 ). However, it is not in all cases that a patient is conscious and thus can make their decisions, sometimes they are unconscious and thus it is upon the family members and the doctor to make a judgment of whether to withdraw the life support or not.
Another argument regards the patient being in a persistent vegetative state, with some arguing that such a person is better off dead because even if they live they will be a burden to themselves and also a burden to the family members. The persistent vegetative state means that the person can never go back to their old self hence cannot think, love, demonstrate care and compassion or relate to others as before (Centre for Healthcare Improvement, 2015). In such a case, the family members can decide to withdraw life support with the advice from the doctor. Doctors, on the other hand, also can decide to withdraw life support under the aspect of "doctor knows best" after they decide that withdrawing the life support is better than keeping it on.
Withdrawing life support from a patient in the persistent vegetative state always brings about mixed feelings, with some people arguing that the death is hastened while others see it as necessary. Those who support the withdrawal argue that there is no new cause of death which is introduced by withdrawing the life support since the death was meant to occur anyway. Withdrawing the life support also does not amount to killing the patient since they could have already died were it not for the supporting machine (Berman, et al., 2014). Those opposed argue that withdrawing the life support is the same as committing murder since it results in the death of the patient.
In most cases, the decision whether to withdrawal or keep the life support is arrived at after careful considerations to avoid ethical issues that may arise from such a decision. Some of the questions to ask to include whether the life support is effective, if it is effective does it result in a burden to the patient or family? An ineffective life support means that even though it is utilized in the process, it results in a burden and it does not enable the person to strive for the goods of life (Gedge, Giacomini, & Cook, 2007). Another aspect considered before the withdrawal of the life support is the main motive or intention of the people removing the life support. In most cases, people assume that for the family or doctor to remove the life support means that they intent to cause the death of the patient. However, removing the life support from the patient means that the move is aimed at removing some form of the physiological, social or spiritual burden from the patient.
Legal Issues
Legal cases concerning the removal or life support from a patient are rare even though sometimes they happen. Such cases can be challenging since they give the judicial system the power to decide whether the patient continues in the current state or not. The central concept for any decision made by the court depends on the patient's best interests, meaning that any decision reached depends on what is good for the patient. Such cases occur in the situation whereby the doctors cannot reach an agreement with a family about the life-sustaining treatment for an adult who lacks decision-making ability (Centre for Healthcare Improvement, 2015). Such cases often result to a lot of distress for the patient, family, and doctor and often revolve around the lawfulness of a certain proposed conduct and thus they decide to seek a court intervention.
In Australia, only supreme courts have the jurisdiction of hearing and resolving end of life disputes and the decisions they make provide authoritative guidance for guardianship tribunals and clinicians in the deliberations. The best way for the supreme courts to decide the cases is by testing whether the proposed treatment by the doctors or family members is in the patient's best interests. The term being in the patient's best interest’s means that whatever action is taken only benefits the patient and nit the family members or doctors. For instance, the Australian law states that futile treatment is not in the best interests of the patient and thus such treatment should be withdrawn (Willmott, White, Smith , & Wilkinson, 2014 ). For example in the Melo and Herrington case, the treatment was discontinued because it was futile to the patient and his condition. The determination of whether the treatment is futile or not depends on the medical determinations as the court cannot determine such a case.
The Supreme Court also explains that an overly burdensome treatment is not in the best interest of the patient and thus should be discontinued. As such, this means that life-supporting treatment methods which have the capability of creating excessive burdens for a patient despite whether they bring benefits are not in the best interests of the patient. The burden may be in the form of potential pain or some type of indignity that the patient can suffer through receiving treatment (Way, Anthony , & Curtis , 2002). Even in the case where the patient is unconscious, the burden concept is also followed since the treatment is being conducted on the patient whether they feel it or not.
The court cases also consider the quality of life that the patient was living with the medical condition and the life they will live after the life support intervention. For instance, a patient who is in the persistent vegetative state is not able to live a quality life after the treatment, and thus the court can decide that the doctor can discontinue the life support. The quality of life can refer to loving, laughing, running, dancing, relating to others and all other activities which the person used to undertake while healthy. Lastly, the court also determines the wishes of the family members in the case where the patient is unconscious, even though such wishes are not determinative (Aitken, Marshall, & Chaboyer, 2016). The wishes of the doctor are also considered, and they can be determinative since the doctor explains the importance of either keeping or withdrawing the life support.
References
Aitken, L., Marshall, A., & Chaboyer, W. (2016). ACCCN's Critical Care Nursing. Sydney: Elsevier Health Sciences.
Berman, A., Snyder, S., Kozier, G, B., Erb, G., Levett-Jones, T., Dwyer, T., . . . Stanley, D. (2014). Kozier & Erb's Fundamentals of Nursing Australian Edition. Sydney: Pearson Higher Education AU.
Centre for Healthcare Improvement. (2015). End-of-life care: Decision-making for withholding and withdrawing life-sustaining measures from adult patients - Part 2 Ethical and Special Considerations. Queensland: Queensland Government.
Gedge, E., Giacomini, M., & Cook, D. (2007). Withholding and withdrawing life support in critical care settings: ethical issues concerning consent. Journal of Medical Ethics, 215–218.
Way, J., Anthony , L., & Curtis , J. (2002). Withdrawing life support and resolution of conflict with families. BMJ, 1342–1345.
Willmott, L., White, B., Smith , M., & Wilkinson, D. (2014 ). Withholding and withdrawing life-sustaining treatment in a patient's best interests: Australian judicial deliberations. The Medical Journal of Australia, 545-547.
