[Withholding and withdrawing therapy--how does the physician make a decision?].
To make a decision concerning the withholding and/or withdrawing of therapy is one of the most difficult tasks in medical care. Similar to other treatment decisions, initiation and interruption of therapy should be guided by the medical indication and, in principle, requires informed patient consent even during end-of-life care. However, especially in this situation, patients are frequently not able to give informed consent or to clearly express their wishes regarding therapy. Therefore, in Germany it is widely recommended to draft a "living will" in order to document the concerned individual's wishes for medical treatment either in general or for specific situations in the case of legal incompetency. Unfortunately, typical phrases of living wills such as "for the case that I am in the terminal stage of an incurable, lethal disease, I hereby wish that..." often do not exactly match the patient's situation or leave the medical team with the difficult task of precisely predicting the prognosis of an individual patient. However, according to a retrospective analysis of two large databases, even sophisticated scoring systems predicted a survival of more than two months in approximately 50% of the patients at one week before their actual deaths and again in 15% of the patients at 24 hours before their deaths. These data emphasise the fact that it is almost impossible to precisely forecast the individual prognosis of terminally or critically ill patients. Consequently, the careful but invariable subjective appraisal of the patient's prognosis and the applicability of the living will by the medical team is of major importance for the decision to withhold or withdraw therapy. Most often, this decision is the result of a cumbersome and controversial debate within the medical team. If a formal living will or any other declaration of the patient's will regarding medical care is lacking, the medical team faces the challenge to explore the patient's putative will by questioning his/her friends and relatives. In order to reach a unanimous decision with relatives and also within the medical team, it may be helpful as a first step to withhold an escalation of therapy for a limited time, while daily reassessing the situation, before it is actively reduced. In Germany, health-care professionals do not always feel certain about the question of whether an active reduction of medical therapy is, in fact, active or passive euthanasia. The German Federal Court of Justice, however, has explicitly stated that withholding and withdrawing therapy is passive euthanasia and as such is legal.
Fachbereich Klinische Anästhesiologie am Evangelischen Krankenhaus Göttingen-Weende. neumann@ekweende.de
Peter
P
Neumann
D016638:Critical Illness / Q000628:therapy; D003657:Decision Making; D005066:Euthanasia, Passive / Q000331:legislation & jurisprudence / Q000523:psychology; D005858:Germany; D006801:Humans; D007258:Informed Consent / Q000331:legislation & jurisprudence; D016224:Living Wills / Q000331:legislation & jurisprudence*; D010348:Patient Care Team; D010817:Physician-Patient Relations; D010820:Physicians / Q000523:psychology*; D011379:Prognosis; D012189:Retrospective Studies; D013727:Terminal Care / Q000592:standards