Professional Statements on Withholding/Withdrawal

2017 Withholding and withdrawing life-sustaining treatment: The Canadian Critical Care Society Position Paper. Can J Anesth. 2017;  CPR should not be provided outside the standard of care” Standard of Care
2016 Defining Futile and Potentially Inappropriate Interventions: A Policy Statement From the Society of Critical Care Medicine Ethics Committee. Crit Care Med. 2016 Sep;44(9):1769-74. 
2015 ATS/AACN/ACCP/ESICM/SCCM Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Resp Crit Car Med 2015; 191(11) 1318-30 This Statement delineates “strictly futile interventions” (for which it does not endorse provision regardless of appeal), from those that are “potentially inappropriate”. Potentially inappropriate treatments “describe treatments that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them. Clinicians should communicate and advocate for the treatment plan they believe is appropriate.” About these, a conflict resolution process is suggested that supports withholding or withdrawal only where another physician willing to provide the treatment cannot be found, AND the SDM is not seeking independent appeal (presumably through a legal process).   Strictly futile; medically indicated; 
2012 American College of Physicians Ethics Manual;Ann Intern Med. 2012;156:73-104 _“In the circumstance that no evidence shows that a specific treatment desired by the patient will provide any medical benefit – the physician is not ethically obliged to provide such treatment (although the physician should be aware of any relevant state law). The physician need not provide an effort at resuscitation that cannot conceivably restore circulation and breathing – but he or she should help the family to understand and accept this reality. The more common and much more difficult circumstance occurs when treatment offers some small prospect of benefit at a great burden of suffering (or financial cost—see “Resource Allocation” within in the Physician and Society section) but the patient or family nevertheless desires it.” Medical benefit
2011 Schneiderman – Wrong Medicine: Doctors – Patients – and Futile Treatment by Lawrence J. Schneiderman and Nancy S. Jecker – k . 2011 John Hopkins University Press 1. Treatment is inappropriate when the patient is permanently unconscious or otherwise unable to appreciate the effects of medical treatment. (must treat the person not just the body) 2. Treatment is inappropriate when it can only sustain the patient in the intensive care unit or acute hospital setting. (preoccupation with their illness precludes meaningful participation in the human community) 3. Treatment should not be offered when it has not worked in the last 100 cases Futile
2007 Legal Liability of Doctors and Hospital in Canada (4th ed.) (Thomson-Carswell) “Once a doctor-patient relationship is formed – the doctor’s obligation is to treat the patient. However – this does not mean that the doctor has a duty to provide (and the patient a correlative right to receive) whatever treatment the patient may request. If a patient requests treatment which the doctor considers to be inappropriate and potentially harmful – the doctor’s overriding duty to act in the patient’s best interests dictates that the treatment be withheld. Likewise – there is no legal duty to perform treatment which the doctor reasonably believes to be medically futile – that is – treatment which offers no prospect of therapeutic benefit for the patient.” Inappropriate – Best interests – Medically futile – Therapeutic benefit
2006 College of Physicians and Surgeons of Ontario Policy Statement # 1-06 – Decision Making at the End of Life “Physicians are under no obligation to provide treatment that will almost certainly not be of benefit to the patient Patient almost certainly will not benefit: There is almost certainly no chance that the person will benefit from CPR and other life support – either because the underlying illness or disease makes recovery or improvement virtually unprecedented – or because the person will be unable to experience any permanent benefit.” Benefit – Recovery unprecedented
2002 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science “Patients or families may ask for care that is highly unlikely to improve health outcomes. Healthcare providers – however – are not obliged to provide such care when there is scientific and social consensus that the treatment is ineffective. If the purpose of a medical treatment cannot be achieved – the treatment can be considered futile. An objective criterion for medical futility was defined in 1990 for interventions and drug therapy as imparting a <1% chance of survival. Although this criterion may be controversial – it remains a basis for current futility research. Without objective signs of irreversible death (eg – decapitation – rigor mortis – or decomposition) and in the absence of known advance directives declining resuscitative attempts – full resuscitation should be offered.” Highly unlikely to improve health outcomes.  Ineffective – <1% chance of survival – Objective signs of irreversible death 
2000 Canadian Critical Care Society Position: Withholding or withdrawal of life support. Journal of Palliative Care 16 Supp. – 2000; s53-62 “When it is clear treatment will not be effective and is not in accord with the standard medical practice or norms – the physician is not obligated to begin – continue – or maintain the treatment” Effective – Standard medical practice
1999 American Medical Association Council on Ethical and Judicial Affairs: Medical Futility in End-of-Life Care Report “[i]f transfer is not possible because no physician and no institution can be found to follow the patient’s and/or proxy’s wishes it may be because the request is considered offensive to medical ethics and professional standards in the eyes of a majority of the health care profession. In such a case – by ethics standards – the intervention in question need not be provided – although the legal ramifications of this course of action are uncertain.” Ethics standards
1997 Consensus statement of the Society of Critical Care Medicine’s Ethics Committee regarding futile and other possibly inadvisable treatments. “[t]reatments should be defined as futile only when they will not accomplish their intended goal.” Treatments that are extremely unlikely to be beneficial – are extremely costly – or are of uncertain benefit may be considered inappropriate and hence inadvisable – but should not be labeled futile. Futility
1995 CMA – Canadian Hospital Association – and the Catholic Health Association Joint Statement on Resuscitative Interventions “There is no obligation to offer a person futile or non-beneficial treatment. Treatment is considered futile when the treatment “offers no reasonable hope of recovery or improvement – or because the patient is permanently unable to experience any benefit” People who almost certainly won’t benefit from CPR are not candidates for CPR – and it should not be presented as a treatment option. Whether this is discussed with the person is a matter of judgment” Non-beneficial – No reasonable hope of recovery – Unable to experience benefit
1995 The Special Senate Committee on Euthanasia and Assisted Suicide: Of Life and Death – Final Report “Futility must be understood very narrowly as treatment that will – in the opinion of the health care team – be completely ineffective.”  Completely ineffective
1992 The Appleton International Conference: Developing Guidelines for Decisions to Forgo Life-Prolonging Medical Treatment  (a) Doctors are not obliged to provide physiologically futile treatments (ie treatments that cannot produce the desired physiological change). Where a doctor considers a life-prolonging treatment not to be physiologically futile – but nonetheless ‘futile’ in another sense of the word because of the low probability of success or because of the low quality of life that would remain – then decisions about the withholding or withdrawal of such treatments should be made in the context of full and open discussion of the nature and extent of the ‘futility’ of the treatment with the patient or the patient’s representative; (b) If a requested treatment entails – according to the norms of medical practice (10) – loss of function – mutilation – or pain disproportionate to benefit – the doctor is not obliged to provide it; (c) If a doctor has a conscientious objection to a requested treatment (11) – that doctor is not obliged to provide it. The doctor should explain all treatment options and his or her position regarding them. If the patient wishes – the doctor should arrange an orderly transition to another doctor of the patient’s choice; (d) Scarcity of resources may sometimes require overriding a patient’s request for a life-prolonging treatment (see Part IV) (12).  Medically futile – Physiologically futile – Disproportionate to benefit – Conscientious objection