Withholding and withdrawing care in acute care: a better death?

Ars Moriendi (“The Art of Dying”) is the name of two Latin texts from the Middle Age – the time of the Black Death. They give advice on a good death. They told readers what to expect, and prescribed prayers, actions, and attitudes to achieve a “good death” and salvation.

The belief that death is the enemy is deeply ingrained in our culture, just as the concept of withholding or withdrawing treatment is taboo in the medical profession. This latter position derives from the Hippocratic Oath – “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them.” Despite comments in mainstream media this viewpoint is not universally supported in the profession…

How should we manage death in ED? Is our duty to the patient, the family or both?

Traditionally our focus is on prompt resuscitation and life support, while investigations and diagnosis continue in parallel. As additional information becomes available we then think about survivable and non-survivable disease. Where is the best place to withdraw/withhold treatment – ED, ICU or a ward? Every day emergency physicians face these moral, ethical and legal challenges, regardless of the country or culture we work in. http://podcasts.bmj.com/emj/2011/05/03/a-propos-du-retrait-de-soins-therapeutiques/

Are we killing patients by stopping support or letting them die with dignity? Is this euthanasia or just a peaceful death? There is such a thing as dignity in death.  Japanese Samurai covered their face with their kimono whilst committing hara-kiri – the ultimate dignity.

Life sustaining measures buy time, allowing relatives and friends to say goodbye and last rites to be completed, important components of grieving.

Doctors are comfortable starting a new treatment, much less so when stopping an existing one. For many, removing life support is like killing the patient.

The patient with non-survivable disease does not need to be diagnosed “brain stem dead” in ICU before withdrawing treatment to make us feel better. Moving a patient to ICU for this, if it is not in the best interests of the patient or the family is wrong; we should manage these deaths in ED.

We should focus on making the patient comfortable, provide staff to support the patient and family during life support withdrawal and provide the right environment for it to occur in.

Dying is indeed a natural process…

Dr Sivanthi Sivanadarajah/Janos P Baombe

Edited by Geoff Hughes

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