Decisions about withdrawing or withholding treatment in palliative care
The goals of palliative care are to manage a patient’s symptoms and suffering, not to intentionally hasten or postpone death. As a patient’s condition deteriorates, the relative benefits and harms or burdens of treatment shift, and decisions about withdrawing or withholding treatment may need to be considered.
Withdrawing or withholding treatment applies to a wide range of medical interventions, including:
- resuscitation
- medication rationalisation
- deactivating implantable cardiac devices
- ventilatory support
- dialysis
- nutrition and hydration.
Decisions about withdrawing or withholding treatment can be difficult and emotional for everyone involved. While withdrawing and withholding treatment are ethically and legally equivalent, the emotional implications of withdrawing treatment can be more difficult to deal with, It is important to negotiate the goals of care and discuss the potential benefits and burdens of treatment with the patient (or their substitute decision-maker) and the family before making a decision; see Discussing goals of care in palliative care. Patients with capacity to make informed decisions about their health care have the right to refuse treatment; patients with diminished capacity should be asked about their preferences. Patient preferences related to withdrawing and withholding treatment are usually discussed as part of #[advance care planning]; ideally this should happen early in the course of a patient’s illnessAdvance Care Planning Australia, 2021. Reassure patients that symptoms associated with withdrawing or withholding treatment will be managed to ensure the patient is comfortable.
Doctors have a duty to recognise when efforts to prolong life may not benefit the patient, and to know when not to start and when to stop attempts at prolonging life; they are not obliged to try to prolong life at all costsMedical Board AHPRA, 2020. Withdrawing or withholding a life-sustaining medical intervention is not physician-assisted suicide or euthanasia; see the End of Life Law in Australia website for detailed discussion of treatment decisions, including decisions about withholding and withdrawing life-sustaining treatment.
A ‘time-limited treatment trial’ may be appropriate if there is disagreement between healthcare professionals and a patient or family about whether a treatment should be continued or a new treatment started. The individuals involved agree to a specified period of treatment and outcome measures, and the patient is monitored. At the end of this period, treatment may be continued if the patient has improved, or withdrawn if the patient has not. For example, a trial of reduction in opioid analgesia to assess if sedation is mainly due to opioids or the dying process itself.
When withdrawing or withholding a treatment, consider whether any other treatments the patient may be receiving should also be withdrawn or withheld (eg when stopping dialysis, consider stopping supportive therapies for chronic kidney disease). For a detailed discussion of rationalising specific drug therapies, see Medication rationalisation in palliative care.
If a decision is made to withdraw or withhold a treatment, ensure that this is communicated to all healthcare professionals involved in the patient’s care.