Is withdrawing life support ethical?

Pangea Reunited, ASN, RN · Jun 13, 2016

What state do they "wake up" in, though?

Wile E Coyote, ASN, RN · Jun 13, 2016

As a critical care nurse for enough years, and other specialties before that, it most certainly is ethical (refer to nonmaleficence). The process of succumbing to a critical illness or injury is not painless and to make one hundred million people linger because of the one that "woke up" is terrible logic. Yes, we need to 'check off lots of boxes' before switching to comfort measures, but to not acknowledge the limits of science is bad medicine. The suffering that my colleagues and I have witnessed...yeesh.

nutella, MSN, RN · Jun 13, 2016

Hello veteran nurses,
I am taking Biomedical Ethics and have chosen to write about patients in persistent vegetative states and whether it is ethical to withdraw feeding tubes and ventilators. I have done research that indicates some patients thought to be facing imminent death wake up. I realize this is the rare rare case, but it does make me wonder how many other of these patients are caught somewhere in between? Can they hear us, understand us, etc? Are we doing them a favor by withdrawing life support?
Please know that I have done a lot of reading on this and by no means am asking someone to write my paper! I am posting here to hopefully gain insight from the experienced nurses on the front lines. All of the info I have read is by doctors and researchers. I want to know what the nurses think.
I am all ears!

First of all ethical questions should be examined within a certain framework and needs to be seen in the context of society the person is living in. Religion can play a huge role in ones understanding of what is ethical. Fore example, if this was a question for the ethics committee, they would go through a certain process to determine the whole ethical picture of your question and in the end make a recommendation.

Generally speaking, withdrawing care almost always invokes strong feelings as staff and family often think "I have killed that person". The questions are - is somebody in a vegetative state "alive"?

I work in palliative care and when a patient has a terminal illness family or the patient sometimes withdraw care with the idea of "letting things evolve the natural way" and to permit a natural death.

Personally, if a patient is truly in a vegetative state, I have no problems with withdrawing care but it should be done within a supportive environment where the family, patient, and staff get the support they need. There can be discomfort for staff with this kind of decision - I believe that staff should volunteer for such an assignment if it conflicts with their own ethical view.

What might be interesting to you in terms of research is the idea to attach a timer to a ventilator in Israel as the Jewish religion views the withdrawal of care in a different way. The idea is to set a timer once the patient is intubated and started on a ventilator. If the family and physician decide that it is futile care they physician will simply let the timer run out and not re-new the order.

Timers on ventilators

This concept may be of interest if you are researching for your class as it address the idea of "withdrawing" care in a different way....

A Framework for Ethical Decision Making - Ethical Decision Making - Ethics Resources - Markkula Center for Applied Ethics - Santa Clara University

Manalo, M. F. C. (2013). End-of-life decisions about withholding or withdrawing therapy: Medical, ethical, and religio-cultural considerations.

Palliative Care: Research and Treatment, 7

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heron, ASN, RN · Jun 13, 2016

One cannot base decisions on what we cannot possibly know, or use very rare occurrences as a reason to prolong the suffering of the vast majority of those in the same circumstance.

In my opinion, of course.

calivianya, BSN, RN · Jun 13, 2016

My personal opinion is that it is unethical to leave someone on prolonged mechanical ventilation and tube feeds, and withdrawing life support is the ONLY ethical choice.

Let's say they are awake and alert underneath that appearance of a coma. They are being stuck every day for ABGs. They are suffering through uncomfortable tubes in their throats and noses that they can't cough back up, and then without their permission we cut a hole in their throats and their abdomens to make new ways for them to breathe and eat. They get stiff from lack of activity and they lose their abilities to move.

We pull on them every few hours - creating sore spots, possibly dislocating their shoulders and hips when we do so especially if they are very obese. I have had obese patients we have extubated wake up and complain about extreme pain in their joints, and I can tell them exactly why they hurt - we have to be able to roll them over somehow. If they are so wide we can't reach across them to grab behind their shoulders/hips, we just have to pull on their arms and legs. If they are on tube feeds and having constant diarrhea, it only gets worse because we have to pull on them more often. Not to mention their butts are breaking down and they are developing huge sores that will take them months if not years to heal.

Even q2h turns are not enough to prevent breakdown in the totally immobile ICU population, especially when they start getting so fluid overloaded their skin is stretched to the breaking point, and it isn't being perfused anyway because of vasopressor use routing blood flow to the important stuff. Their skin starts to break open everywhere, and the skin at their periphery starts to die. Add diarrhea on top of that to their sacrum and it doesn't stand a chance.

Once their skin starts dying, we start rubbing nitro paste on their hands and feet to try and dilate the veins and the arteries in those areas so maybe they can make it out of ICU without getting their hands and feet amputated. I'm sure they probably have massive headaches from that if they are able to feel, but what would you pick - a massive headache 24/7 or the loss of both hands and feet? Odds are those half-dead extremities probably have massive nerve damage and hurt anyway, but I've never had someone wake up from being that sick and have enough brain function left that they could tell me if their hands/feet hurt or not, so I don't know for sure.

If the diarrhea gets watery enough, then we can stick a rectal tube in them, too. I've had patients that after a couple weeks of the rectal tube being inserted, the tube eroded through the lining of the veins in the rectal cavity and the person had to go to endoscopy to get their brand new rectal bleed clipped. Then, they just have to go back to their butt being eroded from tube feed diarrhea because a lower GI bleed is a contraindication for a rectal tube.

OP - do you personally want to live like that? What would it be like to be screaming in your head, "Please stop hurting me!" but no one can hear you? I would personally rather be in solitary confinement in prison for the rest of my life. At least nobody is cutting holes in me and dislocating my joints without my consent in solitary confinement.

8130 · Jun 13, 2016

Thank you for answering my post! This has been unbelievably helpful to me in formulating the true picture of what takes place. I knew nurses were the best people to ask! You are all so experienced and see things how they really are, not just abstract cases in medical journals.

I can't thank you all enough for the detailed experiences these people have and the helpful, thought provoking links provided for me to look at for additional research.

I would not want to live that way. I thankfully understand their reality now! Many, many thanks to all of you.