Clinical Review ABC of intensive care

Withdrawal of treatment

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7205.306 (Published 31 July 1999) Cite this as: BMJ 1999;319:306
  1. Bob Winter,
  2. Simon Cohen

    All medical practice should be governed by basic ethical principles, and intensive care medicine is no exception. Indeed, because of the nature of intensive care ethical issues are addressed almost daily.

    Ethical principles of medical care

    • Autonomy

    • Beneficence

    • Non-maleficence

    • Distributive justice

    Why withdraw treatment?

    Withdrawal of treatment is an issue in intensive care medicine because it is now possible to maintain life for long periods without any hope of recovery. Intensive care is usually a process of supporting organ systems, but it does not necessarily offer a cure. Prolonging the process of dying is not in the patient's best interests as it goes against the ethical principles of beneficence and non-maleficence However, withdrawal of treatment does not equate with withdrawal of care. Care to ensure the comfort of a dying patient is as important as the preceding attempts to achieve cure.

    Dr A decides to continue but not increase the level of vasoactive drug support or inspired oxygen concentration given to a man with multiple organ failure who has been in intensive care for 16 days. Over the next 5 days the patient improves; noradrenaline is discontinued and ventilatory support reduced, and he begins to rouse. He then develops a probable catheter related sepsis and deteriorates. Should Dr A abide by his previous decision of non-escalation? If not, why did he make the decision in the first place? What would he do if treatment was restarted but a similar situation occurred a week later? It would be appropriate (although it might be viewed as inconsistent) to review each requirement for treatment in the light of the patient's current condition

    It is often easier to withhold a treatment than to withdraw it once it has been instituted. Ethically, however, there is no difference between withdrawing a treatment that is felt to offer no benefit and withholding one that is …

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