Withholding and
Withdrawing Treatment
Walter S. Davis, MD
UVA Center for Biomedical Ethics and
Humanities
Associate Professor, Physical Medicine and
Rehabilitation
Withholding Vs. Withdrawing
 Active
Vs passive distinction
 Conventional wisdom in medicine said
withdrawing is “harder” than
withholding
 This has been challenged by modern
medical ethicists - withholding a
treatment that has not been tried is
“morally” harder than withdrawing
one that has not proven beneficial
“Benefits/Burdens Standard”
 Benefits
health benefits - treatment of disease or
symptoms
 quality-of-life benefits - improved mental
status or physical comfort

 Burdens
increased pain, suffering, debilitation
 reduced quality of life
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What do we know about patients’
intensive care experiences?
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There is evidence of significant suffering in ICU
patients with regards to pain, dyspnea, anxiety, sleep
disturbance, depression
A substantial majority of physicians managing ICU
care did not specifically discuss prognosis with
families
54% of family representatives did not understand the
diagnosis and prognosis immediately following a
conference with the treating MD
MD’s do 75% of the talking in family conferences
Challenges Unique to the
ICU Setting
 Often
no prior relationship with patient
or family
 Traditional separation of intensive
care/palliative care
 Patient often not a participant in
discussions
 Families unable to participate in hightech care
Advance Directives
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The “great hope” of the 80’s and 90’s
Do not significantly affect the aggressiveness or cost
of ICU care
Do not change decision-making in the ICU
Can be difficult to interpret for a given patient
What is “terminal”
What is “extraordinary means”
What is “quality of life”
Still an important piece of the puzzle
Brain Death
 Patient
is considered legally dead
 Criteria for diagnosis include
combination of neurologic physical
exam and testing (apnea test/EEG)
 Cardiopulmonary support sometimes
continued until family or others arrive
 Conceptually simple, but can be
difficult in practice
Coma
 Relatively
short-term (weeks)
 Eyes closed, no evidence of wakefulness
 No evidence of communication or
purposeful movement
 Often progresses to PVS
Vegetative State (formally
Persistant VS)
 First
described in 1972
 No evidence of awareness of self or others unable to interact
 Intermittent sleep-wake cycles
 Some preserved cranial and spinal reflexes
 No purposeful behavioral responses
 Timing and diagnostic parameters are under
debate
“Locked-In” Syndrome
 Patients
are awake, alert, with normal
cognition (to the extent that it can be
tested)
 Often caused by pontine infarction or
hemorrhage
 Profound quadriplegia, some preserved
eye movements
 Can be confused with coma or PVS
Landmark Cases in Futility Ethics
 1975
- Karen Ann Quinlan
 1983
- Nancy Cruzan
 1995
- Hugh Finn
 2005
– Terri Schiavo
Quinlan, 1975
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21 yo NJ woman with severe anoxic brain injury after
alcohol/drug overdose
Dx: PVS
Required ventilator and artificial feeding/hydration
Father petitioned to stop vent several months later
Opposed by physicians, backed by local court and
State Attorney General
NJ Supreme Court granted request
KQ died 10 years later
New Jersey Supreme Court in
Quinlan, 1975
“the State’s interest (in the preservation
of life) weakens and the individual’s
right of privacy grows as the degree of
bodily invasion increases and the
prognosis dims. Ultimately, there
comes a point at which the individual’s
rights overcome the State’s interest.”
Cruzan, 1983
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25 yo with PVS after MVA
Required artificial feeding and hydration but not
ventilator
After 4 years, parents asked that hospital stop tube
feedings - hospital refused
Final decision by U.S. Supreme Court affirmed
competent person’s right to refuse any life-sustaining
treatment, and for incapacitated persons, left to the
States the issue of whether legal standard of
substituted judgment would be satisfied by only
verbal statements
NC died 1990, 13 days after feeding tube removed
Finn, 1995
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44 yo television newscaster with PVS after MVA
Wife, sister, and physician wanted feeding tube
removed
Finn’s parents and brothers disagreed
VA Governor James Gilmore intervened to block
removal of tube, citing the State’s interest in
“protecting its most vulnerable citizens”
Decision overruled by local and State Supreme Court
Hugh Finn dies 1998 after removal of tube
Court refuses to force State to pay wife’s legal fees
Schiavo, 2005
1990 - 27yo woman suffers cardiac arrest
secondary to potassium imbalance, with
subsequent anoxic brain injury and PVS
 Husband Michael Schiavo is guardian
 Terri’s parents, the Schindlers, oppose
removing Terri’s feeding tube
 Florida Gov. Jeb Bush intervenes in 2003
 Florida House passes “Terri’s Law” that
allows one-time stay in certain cases

Terri Schiavo’s CT scan
 Left
image shows
brain CT of a normal
25 year old
 Right image shows
Terri Schiavo’s brain
CT at the time of the
debate about her
withdrawal decision
Who opposes withholding and
withdrawing care, and why?
 Advocacy
groups
for persons with
disabilities (NDY)
 “Right to Life”
groups
 Some religious
groups and
organizations
Withdrawing and Withholding
Treatment II – The Role of
Advance Care Planning
Walter S. Davis, MD
Center for Biomedical Ethics
Department of Physical Medicine and Rehabilitation
University of Virginia
Advance Directives
“Living wills”
 “Power of Attorney for Healthcare”
 “Healthcare proxy”
 Appointing a surrogate decision maker is
usually considered the most useful AD
 Details and circumstances of clinical
situations are dynamic and often difficult to
predict (sometimes)
 Legal requirements vary by state, and are
summarized at caringinfo.org
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Advance Care Planning
Getting information on tx options
 Deciding on treatment preferences
 Getting info on how disease or serious illness
might progress
 Discussion w MD about treatment goals,
risks, benefits
 Sharing personal values with loved ones
 Using AD to put into writing preferences about
life-sustaining treatment specific to the patient
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Problems with
AdvanceDirectives
 In
a survey of almost 5,000 charts:
66% were durable power of attorney
 31% were standard living wills or other
written instructions
 Only 3% provided additional instructions
for medical care, and even fewer contained
specific instructions about the use of lifesustaining medical treatment
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More problems…
 Legal
requirements and restrictions may be
counterproductive
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Obtaining witness signatures and notarizing may
be difficult to make happen in a Dr.’s office
State hierarchy laws can be inflexible and may not
apply in certain situations
The emphasis should be on the discussion about
end of life care, and not on signing the legal
document
Issues to be considered in
end-of-life discussions
 Overall
attitude towards life
 Attitudes about independence and control,
and the loss of them
 Religious or spiritual beliefs and moral
convictions
 Views on health, illness, death and dying
 Feelings toward doctors, other caregivers,
and the “culture) of modern medical care
Opportunities for discussion
about end-of-life issues
life events – marriage, birth, death of
a loved one, retirement, birthdays, etc.
 While drawing up a will or other estate/financial
planning
 Before and after annual physicals, particularly
when the patient has one or more chronic
conditions
 Significant
The role of the physician
 Explaining
and informing on the
illness/disease process – to pt and
proxy
 Discussion of pain management options
 Learning the patient’s views on quality
of life, role of spirituality/religion
 Working out the details of how the plans
will be carried out
 Education and discussion on hospice
and palliative care
Ethics consult case – MR C
 53
yo with ESRD, schizophrenia,
admitted with shortness of breath
 Dx’d renal failure, fluid overload,
recommend dialysis
 Pt refuses dialysis, but wants to be a
“full code”
 Pt’s family wants him to receive dialysis
Ethics consult case – Mr C
 Pt
found to have decisional capacity by
psychiatry consult team, schizophrenia
not an issue in this decision
 Renal Clinic note found indicating
patient did not want dialysis in any
situation, but did want to be full code
otherwise
 Further discussions with patient
revealed he did not want to die “choking
for air,” but would be DNR if sxs treated
Ethics Consult case - CG
 69
yo with ALS (amyotrophic lateral sclerosis)
 AD appoints daughter as POA for healthcare
and specifies durable DNR
 CG plans to die at home with hospice care,
but is in a rehab center for a one week stay to
get mobility equipment and training for family
 Falls from his wheelchair, admitted to ED
short of breath, dx’d with pneumothorax