Doctors examine right way to withdraw life support
National guidelines being developed
Canada’s critical-care doctors are confronting one of the most sensitive issues in endof-life care: Once the agonizing decision has been made to remove someone from life support, what’s the most appropriate way to do so?
The first national guidelines are under development on the best way to withdraw life support in patients expected to die. The goal is to set standards for care, support grieving families and minimize the patient’s pain or distress while they’re dying, but still alive. The issue of who, ultimately gets to decide — doctors or families — whether life support should be withdrawn made headlines in Canada this year, most famously with the case of Hassan Rasouli, a comatose Toronto man whose family succeeded in having the Supreme Court of Canada prevent doctors from unilaterally removing Rasouli from his breathing machine.
But while numerous guidelines exist around deciding when to stop life-sustaining treatments, there’s little to guide doctors on the actual withdrawal of life support — including how to avoid doing anything that could be construed as hastening or speeding death.
“There isn’t a lot of evidence around the ideal way to do this,” says Dr. James Downar, a critical care and palliative-care doctor at the Toronto General Hospital who is helping develop the guidelines with the Canadian Critical Care Society.
“There’s no way you could ever get the best possible evidence for this type of thing, because the best possible evidence would be if we could interview the patients once they have died, and ask, ‘How did it go? What was the quality?’ ” says Downar.
Ten to 30 per cent of people who die in hospital die in intensive-care units. The vast majority of ICU deaths occur through the withdrawal of life support, in most cases, a ventilator or breathing machine.
When ventilation is discontinued, the person’s oxygen level falls while carbon dioxide rises. Death often takes 30 or 40 minutes but it could be almost immediate — or many days later. The other approach is to go slowly, dialing down the settings and slowly weaning the patient off ventilation. In Japan, it’s known as the “soft landing,” Downar says — “don’t do anything sudden so that nothing looks as if it caused the death of the patient.”