Withholding and withdrawing life-sustaining treatment

Abstract

Population-based studies have demonstrated that a significant and increasing proportion of deaths is preceded by a decision to withhold or withdraw life-sustaining treatment, defined as a treatment without which life would, with a very high probability, end within a foreseeable period. This chapter discusses ethical considerations around withholding and withdrawing life-sustaining treatments with a focus on neurologic disease. I discuss epidemiology, definitions and terminology, the ethical criteria for guiding decision-making and present a goals of care-based algorithm that may help make clinical decisions near the end of life. This algorithms suggests that treatment should not be administered unless it is both medically appropriate (indicated) and supported by the patient's autonomous will. If patients or proxies demand a treatment considered medically inappropriate, the ethically correct response depends on the analysis of the underlying reasons of conflict. The chapter ends with some practical suggestions concerning advance care planning, palliative care consultation and clinical ethics consultation.