ABSTRACTS from 16th International COnference on ... - CRRT Online

H32
Withdrawing & Withholding Support for AKI: Ethical Issues in the ICU
Noel Gibney MB FRCP(C)
8:00-9:30
Thursday, February 16
Educational Objectives:
To provide perspective on end of life care in critical care units.
To outline principles for decision making in withholding and withdrawing life support technologies in the critically
ill.
Using case histories to outline process of decision making in end of life care of critically ill patients with AKI.
Content Description:
Although there are major differences across regions and countries, in general, the vast majority of patients who
die in critical care units do so after either the withholding or withdrawal of life support therapies. Observational
studies documenting physician behavior have noted changes in the modes of patient deaths and an earlier abandonment
of life-sustaining treatments. Limitations are associated with patient age, diagnoses, ICU stay, and geographic
and religious factors. In North America, medicine has moved <strong>from</strong> a paternalistic model to one that promotes
autonomy and self-determination.
Patient expectations and preferences now help shape end-of-life practices, limiting the use of technologies that
may prolong dying rather than facilitate recovery. In other geographic regions, patient-physician relationships
are still somewhat paternalistic. This can be difficult for patients, families and health care professionals. On the
other extreme, active shortening of life is practiced in a small number of countries. Seriously ill patients and
family members have defined the importance of various elements related to quality end-of-life care. The most
important elements related to trust in the treating physician, avoidance of unwanted life support, effective communication,
continuity of care and life completion.
Variation in the perception of what matters the most indicates the need for customized or individualized
approaches to providing end-of-life care. There are established guidelines for withholding or withdrawal of renal
replacement therapy in patients with AKI. These include estimating prognosis and addressing the issues of
advance directives and patient and family preferences through the process of shared decision-making to clarify
appropriate strategies for clinical management and interventions. Time-limited trials of dialysis may be an
invaluable tool in this process.
Suggested Reading:
Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J
Respir Crit Care Med. 1998 Oct;158(4):1163-7.
Sprung CL, Maia P, Bulow HH, Ricou B, Armaganidis A, Baras M, Wennberg E, Reinhart K, Cohen SL, Fries
DR, Nakos G, Thijs LG; Ethicus Study Group. The importance of religious affiliation and culture on end-of-life
decisions in European intensive care units. Intensive Care Med. 2007 Oct;33(10):1732-9.
Sprung CL, Woodcock T, Sjokvist P, Ricou B, Bulow HH, Lippert A, Maia P, Cohen S, Baras M, Hovilehto S,
Ledoux D, Phelan D, Wennberg E, Schobersberger W. Reasons, considerations, difficulties and documentation
of end-of-life decisions in European intensive care units: the ETHICUS Study. Intensive Care Med. 2008
Feb;34(2):271-7
Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH, Kaufman DC; American
Academy of Critical Care Medicine. Recommendations for end-of-life care in the intensive care unit: a consensus
statement by the American College [corrected] of Critical Care Medicine. Crit Care Med. 2008
Mar;36(3):953-63.
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