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Arch Hellen Med, 27(1), January-February 2010, 18-36


End-of-life dilemmas in the intensive care unit:
Withholding and withdrawal of life sustaining treatment

National and Kapodistrian University of Athens, Medical School, First Critical Care Department, "Evangelismos" General Hospital, Athens, Greece

Intensive care may prolong the dying process in patients who have been unresponsive to the treatment provided and for whom the possibility of survival or regaining an acceptable quality of life is nil. The withholding and withdrawal of life-sustaining treatment were introduced to avoid the futile suffering of dying patients. These practices are based on the principles of bioethics; they are common worldwide and have been approved by the international scientific community. They must not be confused with euthanasia. There is no ethical distinction between withholding and withdrawal of treatment. Any life-sustaining modality can be withheld or withdrawn, including artificial nutrition and hydration. The great majority of patients in intensive care units (ICU) are incapacitated. Advance directives may extend the autonomy of patients. Medical societies recommend a model of shared decision making, in which the medical team and the relatives share the responsibility for decisions. The goals of treatment are determined through a procedure of discussion and information exchange. When treatment cannot fulfill its defined goals, it is considered non-beneficial and is withheld/withdrawn. Conflicts may arise, in which case, an effort to improve communication is needed. Unsolved disagreements are referred to the hospital ethics committee. Observational studies conducted in several countries on different continents showed that a large proportion of ICU deaths are preceded by withholding/ withdrawal of treatment, and that a variety of clinical factors are associated with the decision to limit treatment. The frequency of withholding/withdrawal of treatment and the degree of involvement of relatives in the decision making are influenced by the cultural context.

Key words: End-of-life dilemmas, Euthanasia, Principles of bioethics, Withdrawal of treatment, Withholding of treatment.

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