Withholding LST - This involves a conscious decision to not initiate such treatment. For example, a patient may refuse to be placed on a ventilator.
Withdrawing LST - This involves a conscious decision to stop or remove LST after it has begun. For example, a patient on a ventilator may demand to be taken off the ventilator.
Competent patients have the right to refuse or stop any treatment including artificial nutrition and hydration, even if it is necessary to sustain life. This was confirmed by the U.S. Supreme Court in Cruzan v. Director, Missouri Department of Health, 497 U.S. 461, 110 S. Ct. 2841, 111 L. Ed. 2d 224 (1990). The Court ruled that patients without decisional capacity also have this right. But states can determine the standard of evidence necessary to prove that the patient would have refused this treatment.These standards include:
As with any important decision, one should ensure that the individual has been
fully informed, comprehends this information and the consequences of his/her
decision, and is capable of making a rational decision. If the decision-maker
is not the patient, then the decision should be in keeping with the patient's
values or interests, if known.
Treatment can also be withdrawn or withheld based on factors other than the
patient’s decisions. These include but are not limited to:
These reasons are more controversial because they go beyond simply respecting a patient’s autonomy and privacy rights to include judgments about quality of life, the best use of limited resources and justice. While a patient’s right to refuse treatment is almost universal, patients do not have the right to demand any treatment.
There is no legal difference between withholding and withdrawing life-sustaining treatment. While the majority consensus is that there is no moral difference between withholding and withdrawing treatment, all else being equal, some people find withdrawing LST more difficult than withholding. There are also some religions that make a distinction. In specific cases, one may be preferable to another. For example, a patient may be willing to try a treatment with an uncertain outcome if he/she is assured that the treatment will be stopped when it has been proven to be ineffective or whenever the patient requests that it be stopped. On the other hand, some patients may be unwilling to undergo the treatment at all. Respecting these decisions is necessary for respecting the patient as an autonomous human being. Respecting the right to withdraw treatment enables patients/surrogates to be more informed about the prognosis by allowing a trial of treatment.
Refusal of life-sustaining treatment does not mean that the patient does not
desire other forms of care. Patients may refuse a LST, but still require good
palliative care and basic care. Also, some patients may wish to receive some
LST and not others (e.g. For religious reasons, a patient may desire artificial
nutrition and hydration, but not other LST.). A do-not-resuscitate order does
not mean do-not-treat. It only refers to resuscitation. Some patients with DNR
orders even have surgical procedures.
Even though the societal mores support the patient's right to have life-sustaining
treatment withheld or withdrawn, this is often emotionally difficult for those
involved. If a health care professional(HCP) cannot in good conscience abide
by the patient/surrogate's decision, then the HCP should inform the patient
or surrogate and assist in the transfer of care to another HCP who is willing
to abide by the decision. Furthermore, compassion and understanding are essential
when helping the patient, family, and colleagues with these decisions.
Withholding or withdrawing life-sustaining treatment does not necessarily
constitute assisted suicide or euthanasia, although the outward actions may
be similar. The intent of the health care professional is not to cause the patient's
death. The primary intentions are to respect the patient's autonomy, to limit
pain and suffering, and to improve the patient's quality of life. Failure to
respect a competent patient’s treatment refusal is a violation of that
patient’s right to control what is done to his/her body. The American
Nursing Association and American Medical Association have clear statements on
this in their codes of ethics.
Treatment can be withheld or withdrawn if it is outside the realm of reasonable
practice. Patients have a right to refuse treatment. But they do not have a
right to demand treatment, especially if that treatment is outside the realm
of reasonable practice. These situations still need discussion with the patient
or surrogate to foster understanding and provide care that addresses the patient’s
needs and concerns.
CKP 5/25/05