End of Life Issues: Part Two

When Is It Okay to Withdraw Treatment?

by William Cutrer, MD, and Sandra Glahn, ThM

One of the most sensitive, complex issues or our day concerns the end of life and how to die well. Most of us would like to live to a ripe old age, call our families together, give them each an ample inheritance, and then die peacefully in our sleep. Unfortunately, it doesn’t always work that way and both the terminally ill and their families face difficult decisions. Is it ever right to withhold treatment? Is it okay to withdraw treatment once it has been initiated? Christians have struggled with these dilemmas, wondering if “revering life” must mean “prolonging life at all cost.” Or might we sometimes “prolong death”? In such cases, might cessation of medical intervention be the right course?

Death entered the world when sin did. And as believers in Christ die, we continue our new, eternal life without the stain of sin. From the Christian perspective, physical death isn’t the worst thing imaginable—in fact, to be absent from the body is to be present with the Lord (2 Cor. 5:8).

In past columns, we’ve set out the four principles of ethics. So let’s consider an actual “end of life” case through the grid of these four principles:

A Case Study

Leonard, an 88-year-old Christian man is hospitalized following a serious stroke. He is able to open his eyes and recognize loved ones, but cannot speak or swallow. Because of the stroke, he has been placed on a ventilator and is dependent on it for sufficient oxygen. The medical team has asked the family to answer a question: If Leonard has another stroke and a cardiac arrest, should he be resuscitated?

Autonomy. When the patient is unable to communicate, the principle of autonomy becomes hazy, unless the patient has documented personal desires with a living will. This document outlines what the patient does and does not want done in the event of his inability, which can be of enormous value to the family. Another option is a “durable power of attorney for health care. This document names a person who may make the choices in the event of a patient’s inability. Almost no one wants to live dependent on a ventilator with no hope of recovering consciousness.

Does the patient have the right to refuse care? Yes he does, if he can. Only in a few rare cases can a physician treat a patient against his or her will.

Beneficence. This requires that we “do good” or seek the good for the patient. Yet in this case, exactly what would that be?

Doctors make decisions based on the answers to two questions:

(1) Is the condition reversible or recoverable? Certainly aging cannot be reversed, but the effects of a stroke often decrease over time. However, a patient with metastatic, recurrent cancer that has not responded to any available means of therapy would pose a different set of considerations.

(2) Does a respect for the sanctity of life require the initiation and maintenance of all conceivable therapies in the face of no reasonable hope for recovery?

Justice. We must give the patient his or her right or due. In this case—in the absence of the expressed desire of the patient—what exactly is his “right”? And what is the “right thing” for the patient?

Nonmaleficence. We must commit to doing no harm. But is withholding or withdrawing treatment “doing harm” when the likely result will be the death of the patient?

Having posed the usual questions, recognizing the sensitivity of an issue such as the impending death of a loved one, how can we determine what is right? How can we help those we care about to make these decisions or how do we make decisions for them if they are unable?

Several helpful decisions can be made once we’ve answered a few more questions. Is curative therapy—or only comfort care—available? We must never withdraw “care” that seeks to make the patient more comfortable. But sometimes the “treatment” or curative therapy is neither helpful nor comfortable. Generally, supportive care, such as food and water are appropriate. However, as the patient nears death, even providing food and water can worsen his or her condition.

In our test case, Leonard has not reached the stage of absent brain function, and supplemental nutrition would seem appropriate and a comfort-care issue. The greater question is this: Should he be resuscitated in the event of another stroke and placed on a ventilator for support? This is more complex. In fact, Leonard will never be any younger, but eighty-eight may not be his full complement of years. Yet, if the medical team resuscitates him after a stroke that has irreversibly damaged his conscious capacity, he is left fully dependent on machinery.

Let’s suppose that Leonard does arrest, and because there has been no DNR (Do Not Resuscitate) order, he gets the “full code.” His heart rhythm is restored; he is on a breathing machine. Further evaluation shows that this stroke indeed has done vast and irreversible damage to his brain function. He will never wake up. Can the family, in good conscience, make the decision to remove the ventilator, to “unplug” the machine that is keeping him alive?

Again, we have no documented expression of the patient’s desires, so the decision will fall upon the family at the bedside. In this instance, what does it mean to “do good and not harm”? Is withdrawing life support the same as “killing” the patient? Is the “good thing” to keep him alive as long as possible using the breathing machine and the feeding tube?

No Easy Answers

There is room for disagreement among godly people here. The family—after prayerful consideration—may in fact, discontinue life support. We have now reached an irreversible condition for which there are no known therapies. In fact without the medical advances, which include ventilators, Leonard would already be with Christ.

Intent: Life or Death?

The “intent” of the action, not just the result, has considerable importance. As you will read in the upcoming column on “active euthanasia,” in which the doctor injects a lethal dose of medication, the intent is to kill the patient. In the case at hand, the withdrawal of “life support,” while likely to result in the death of the patient, actually allows for voluntary, unaided breathing if the patient is able to do so. There is still plenty of oxygen in the room so that if Leonard could sustain his own life without artificial support, he would live, not die.