Ethical and practical considerations of withdrawal of treatment in the intensive care unit.

Purpose: To discuss the medical, ethical and legal basis of decisions to discontinue life-support therapy in the adult intensive care unit (ICU), and to provide practical guidelines for the discontinuation of life support therapy.

Source: Relevant articles were retrieved through Medline (1991-present; terms: ethics, life support discontinuation, double effect, beneficence, non-maleficence). Other sources include legal references, and personal files.

Principal Findings: Understanding the legal and ethical principles of autonomy, beneficence, non-maleficence and double effect are crucial when withdrawing life support therapy. The law respects a competent patient's right to direct his/her healthcare but does not uphold his/her right to demand futile care. Surrogate decision makers can be used when the patient is incompetent, provided they are acting in the patient's best interest. Euthanasia is illegal and the distinction between discontinuation of therapy and euthanasia is legally clear. Skillful administration of palliative therapy cannot be construed as euthanasia when the aforementioned ethical principals are respected. The various practical methods of discontinuing therapy are discussed. Every ICU should develop its own guidelines and a checklist to help caregivers during this difficult time. Caregivers must anticipate the mechanism of death and direct interventions at the symptoms that are likely to cause discomfort. Drugs and dosages must be individualized, and depend on the underlying disease, anticipated mechanism of death, and the patient's pharmacological history. When prescribing a drug, the intention should be clear.

Conclusions: Appropriate discontinuation of therapy in the ICU allows patients a dignified and comfortable death.