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David A. Gruenewald, MD; Stephen C. Ezeji-Okoye, MD; Ware G. Kuschner, MD, FCCP; Alice Beal, MD, FCCP
Author and Funding Information

Affiliations: Veterans Affairs Puget Sound Health Care System Seattle, WA,  Veterans Affairs Palo Alto Health Care System Palo Alto, CA,  Veterans Affairs New York Harbor Health Care System New York, NY

Correspondence to: David A. Gruenewald, MD, VA Puget Sound Health Care System, Geriatrics and Extended Care Service, 1660 S Columbian Way, S-182-GEC, Seattle, WA 98108; e-mail: david.gruenewald@va.gov


The authors have no conflicts of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;135(6):1697. doi:10.1378/chest.09-0392
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To the Editor:

Rady and colleagues1 have raised concerns about the implementation of our guidelines2 and clinicians' intentions in end-of-life care. We acknowledge that our guidelines do not eliminate moral confusion about end-of-life care in the ICU, and we agree that a focus on intention should be included in any moral appraisal of human action. While our guidelines, template physician note, and order set do not regulate the integrity of clinicians' actions, they do provide a normative basis around which consensus regarding best practices can develop. That is, they provide a standard framework for developing and communicating the goals of care and support consistency in efforts to achieve them.

Guidelines for the withdrawal of life-sustaining treatment and other palliative measures of last resort, such as palliative sedation, make a distinction between palliation and euthanasia not only on the basis of clinician intention (symptom relief vs patient death), but also on the basis of methods (use of sedative medications sufficient to relieve symptoms vs administration of lethal medications) and the definition of successful outcomes (removal of treatments that are no longer desired or do not provide comfort vs patient death).3,4 Moreover, the rationale for permitting patients and their surrogate decision makers to stop life support is based not only on clinician intention, but also on patient autonomy and informed consent, and the principle of proportionality.4,5 Miller and Truog5 have observed that this rationale exists apart from the question of whether withdrawing life support causes death. The principle of proportionality requires us to consider the patient's condition (eg, intensity of suffering, expected survival), the anticipated benefits of withdrawal of life-sustaining treatment (minimization of suffering), and the expected harms (possible shortening of survival time); then, to conclude that the cessation of life-sustaining treatment is the most proportional action among the available choices.4

Rady and colleagues1 expressed concern regarding the titration of medications to achieve comfort. Titration is central to successful symptom management in palliative medicine. Moreover, opioids and sedatives may prolong life rather than hasten death after ventilator withdrawal in critically ill patients.6

In delivering palliative care at the end of life, the subjective experience of patients and family is of paramount importance; objective metrics are typically less relevant. The decision made by the patient or a surrogate decision maker to shift treatment goals to comfort care is consequential: the primary goal of health-care providers shifts to keeping the patient comfortable. Except for the magnitude and the immediacy of the consequences, such a choice is like others we support in the course of clinical care. Accordingly, the withdrawal of life-sustaining treatment in these situations honors the individual's autonomy and is the most proportionate response in desperate circumstances without a more desirable and achievable outcome. Finally, it continues to be our impression that our guidelines, template physician note, and order set support patient autonomy at the end of life, as well as strengthen understanding about palliative care practices in our ICU, reduce ethical conflicts, and improve patient care.

Rady MY, Verheijde JL, McGregor JL. Clinical guidelines and clinicians' intentions in end-of-life care. Chest. 2009;135:1696-1697. [PubMed] [CrossRef]
 
Kuschner WG, Gruenewald DA, Clum N, et al. Implementation of ICU palliative care guidelines and procedures: a quality improvement initiative following an investigation of alleged euthanasia. Chest. 2009;135:26-32. [PubMed]
 
Rubenfeld GD. Principles and practice of withdrawing life-sustaining treatments. Crit Care Clin. 2004;20:435-451. [PubMed]
 
Morita T, Bito S, Kurihara Y, et al. Development of a clinical guideline for palliative sedation therapy using the Delphi method. J Palliat Med. 2005;8:716-729. [PubMed]
 
Miller FG, Truog RD. Rethinking the ethics of vital organ donations. Hastings Cent Rep. 2008;38:38-46. [PubMed]
 
Bakker J, Jansen TC, Lima A, et al. Why opioids and sedatives may prolong life rather than hasten death after ventilator withdrawal in critically ill patients. Am J Hosp Palliat Care. 2008;25:152-154. [PubMed]
 

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References

Rady MY, Verheijde JL, McGregor JL. Clinical guidelines and clinicians' intentions in end-of-life care. Chest. 2009;135:1696-1697. [PubMed] [CrossRef]
 
Kuschner WG, Gruenewald DA, Clum N, et al. Implementation of ICU palliative care guidelines and procedures: a quality improvement initiative following an investigation of alleged euthanasia. Chest. 2009;135:26-32. [PubMed]
 
Rubenfeld GD. Principles and practice of withdrawing life-sustaining treatments. Crit Care Clin. 2004;20:435-451. [PubMed]
 
Morita T, Bito S, Kurihara Y, et al. Development of a clinical guideline for palliative sedation therapy using the Delphi method. J Palliat Med. 2005;8:716-729. [PubMed]
 
Miller FG, Truog RD. Rethinking the ethics of vital organ donations. Hastings Cent Rep. 2008;38:38-46. [PubMed]
 
Bakker J, Jansen TC, Lima A, et al. Why opioids and sedatives may prolong life rather than hasten death after ventilator withdrawal in critically ill patients. Am J Hosp Palliat Care. 2008;25:152-154. [PubMed]
 
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