Changing attitudes and practices in forgoing life-sustaining treatments

Article Abstract:

Recent advances in medical technology that allow people to remain alive longer, often with considerable suffering and cost, have raised new, disturbing questions about doctors' and patients' responsibilities for continuing life. Some of the changes in medical practice and the evolving attitudes about prolonging life are presented. Cardiopulmonary resuscitation allows the 'normal' dying process to be interrupted, but can leave the victim with irreversible brain damage. In 1968, the definition of death was moved from terms accessible to the layman (cessation of heart and lung activity) to a more arcane province as 'irreversible coma' became a new criterion. In the case of Karen Ann Quinlan, a 22-year-old who became comatose after allegedly ingesting alcohol and tranquilizers, her parents won the right to remove a ventilating machine, even though she did not meet the criteria for brain death. This landmark case, decided in 1975 by the New Jersey Supreme Court, opened the way for courts to decide matters formerly left to the medical profession. Discontinuing artificial and intravenous feeding has been another important subject of debate. In a 1983 survey, 73 percent of physicians, who responded to questions about a hypothetical comatose patient with no hope of recovery, said they would give sufficient fluids intravenously to maintain the patient, and 40 percent said they would even use invasive means to set up an intravenous line. However, 27 percent of the physicians responding to the survey said they would not give adequate intravenous fluids. Removal of such life-sustaining treatment was considered a deviation from standard practice in 1981, in the case of Clarence Herbert, when two physicians were prosecuted for discontinuing fluids and nutrition. Subsequently, the California trial court ruled that medical procedures to provide fluids and nutrition are more similar to other medical procedures than they are to typical human nourishment. However, today between 85 and 90 percent of critical-care workers would withhold hydration and feeding in certain cases. The Massachusetts Supreme Judicial Court's decision that Paul Brophy had the right to have a gastrostomy tube (a tube inserted directly into the stomach for the delivery of food) removed was controversial. Although the patient had remained in a vegetative state for two years after an aneurysm (weakened artery) in his brain ruptured, his condition was not life-threatening. Brophy had previously stated that if he was in a vegetative state he would not want his life to be prolonged. Similar cases are discussed. (Consumer Summary produced by Reliance Medical Information, Inc.)

Medical law

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The road to euthanasia

Article Abstract:

According to an article by Charles L. Sprung in the April 25, 1990 issue of the Journal of the American Medical Association, American physicians have advanced far down the road to euthanasia (mercy killing). Sprung advances the positions that the definition of 'death' has been revised to include a chronic vegetative state, and that the standards for maintaining life have slipped. However, the changes in medical attitudes, which have occurred during the last 25 years, need not be seen as a loss of morality among medical professionals. In fact, evidence exists that courts are now acting to prevent withholding treatment from terminally ill patients, as the case of Nancy Cruzan illustrates. In 1988, the Missouri Supreme Court refused to allow the feeding tube to be removed from this patient, who had been in a vegetative state for five years. (This case was heard by the US Supreme Court in December 1989, but a decision had not yet been handed down.) Questions about the ethics of withholding treatment, and allowing patients to die have been brought on by new technologies. They are societal and individual in nature, and must be solved in a manner that allows individuals to retain their dignity and integrity. Answers will evolve from discussion among people advocating many different positions, including those similar to the ones presented in Sprung article. (Consumer Summary produced by Reliance Medical Information, Inc.)

Management, editorial

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End-of-life practices in European intensive care units: the Ethicus study

Article Abstract:

There is widespread variability in the treatment of terminally ill patients in Europe, according to a survey of 37 intensive care units in 17 European countries. Many ICUs withheld or withdrew life-sustaining treatments and some even used drugs to shorten the dying process. Limitations of life-sustaining treatments depended on the patient's age, diagnosis, religious views, and number of days in the ICU.

Europe, Demographic aspects, Surveys, Terminal care, Intensive care units

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