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Withdrawing Care:

Factors that Influence the Decision to Withdraw

Amber R Hart

Washburn University MSN

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Abstract

This article discusses the decision to withdraw care of the unconscious end-of-life patient

in the intensive care setting and the factors that influence the family’s decision to withdraw care.

The factors that may lead a family to withdraw care include advanced directives, religion, patient

age, and race. By better understanding those factors, health care providers can give the patients

and their families a better end-of-life experience.

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Withdrawing Care: Factors that Influence the Decision to Withdraw

The decision to withdraw medical care from a patient is not an easy one. It generally

includes the physician’s prognosis, the patient’s wishes, and the family’s decision. Some patients

are not conscious to make their own medical decisions. Those patients depend on their family to

make the decisions regarding end-of-life care. This decision may be influenced by a patient’s

advanced directives, race, religion, or other factors. It is important for healthcare providers to

understand those factors or influences that may bear weight on a decision to withdraw.

In most cases, generally in an intensive care unit, a patient’s family is approached by

more than one physician regarding the patient’s prognosis. When the prognosis is poor, the

physicians discuss the patient’s options with the families. These options usually include

continuing aggressive care, continuing conservative care, making the patient a do not resuscitate,

withdrawing, or withholding care.

Aggressive medical care is the use of procedures and medications to mitigate, cure, or

halt the progression of harmful disease (Jonas, 2005). Aggressive care would include doing

anything and everything possible to continue the patient’s life. Aggressive care does not take into

consideration the possible outcomes of quality of life following care for the illness. Studies show

that aggressive care is more likely to cause poor quality of life for patients and depression in the

caregivers that must take care of those patients. It also leads to worse bereavement adjustment

for the caregivers and family following the patient’s death (Barclay, 2008).

Conservative medical care is the care and management of a patient to combat or prevent a

disease, disorder, or injury without the use of radical measures and procedures (Mosby, 2002).

Families will chose conservative care if the patient has an advanced directive stating this wish or

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if they are aware of the poor prognosis but are not ready to withdraw care. Many times this

includes not performing a surgery, not beginning dialysis or continuous renal replacement

therapy, or not initiating mechanical ventilation if necessary.

If a patient does not already have a do-not-resuscitate (DNR) order placed on their chart,

or it is not stated in their advanced directives or a living will, a family may choose to make their

loved one a DNR. A family may not want cardiopulmonary resuscitation or intubation but still

want aggressive care. The family is aware of the poor prognosis but would like to continue

aggressive or conservative care until cardiac death would occur. Usually they understand the

process of cardiopulmonary resuscitation (CPR) and do not want their loved one to go through

CPR knowing the probable outcome and other medical problems that can be caused by CPR.

End-of-life conversations happen between physicians and family when the physicians

feel the patient has a less than ten percent chance of survival, the patient already has some type

of living will or advanced directive to state their preference, or the physician feels the patient

will have a poorer cognitive function despite aggressive care (Gabrielli, Layon, Yu, 2008). A

physician is more likely to withdraw care than to withhold care on a patient (Gabrielli, Layon,

Yu, 2008). Withdrawing care on a patient includes a trial of care to see if the care would make a

difference in the patient’s outcome while withholding care is to never initiate aggressive care

(Gabrielli, Layon, Yu, 2008). A physician may choose to withhold care if the “treatment has

been deemed inappropriate, not enough of a particular treatment available, or the client or family

has refused it” (Rosdahl, Kowalski, 2008).

Ethics committees have become increasingly popular to assist in the decision with and to

make recommendations for end-of-life care. Withdrawing care on a patient is an ethical issue and

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to ensure the physicians and staff are correct in their prognosis, having an ethics committee

representative may be helpful for all members involved. Ethics committees generally review a

patient’s case and medical status and determine if aggressive care is futile. They can also help to

review any advanced directives to make sure the patient’s wishes are being honored (Lachman,

2010).

Advanced directives can be drawn up by a patient prior to admission to a hospital. The

advanced directives can include a living will that state what the patient does and does not want

done with regards to their medical care. This may include a do-not-resuscitate order, a do-not-

intubate order, preferences on dialysis, preferences on surgery, or any other procedures that may

prolong a patient’s life. A patient may also have a durable power of attorney. The durable power

of attorney is an appointed person designated to make decisions for the patient when the patient

is unable to do so them-self. Some people may have a person appointed and also an alternate in

case the first person appointed is also unable to make decisions. Each state has their own laws

and own forms for living wills and durable power of attorneys (Advanced Directives, 2011).

In the event a person is not able to make their own healthcare decisions, the patient must

rely on an already appointed durable power of attorney or their next of kin to make their

decisions for them. If a person has a living will or an advanced directive in place, unfortunately,

their durable power of attorney or next of kin can override those wishes when the patient is not in

the capacity to verbalize their wishes (Understanding CPR and DNR, 2011). It is extremely

important for patients to discuss their wishes with their families or power of attorneys so that

their wishes are honored in the event the patient cannot express them.

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Studies show that advanced directives aid in the care of the patient who cannot express

their wishes. Most patients who have advanced directives in place are inclined to want limited

treatment done (Silveira, Kim, Langa, 2010). Of those patients who want limited treatment, a

majority of their wishes are honored. Those patients who request full, aggressive care are more

likely to receive aggressive care. However, those that had no advanced directives were more

likely to receive limited care (Silveira, Kim, Langa, 2010). There is limited data on the

effectiveness of a durable power of attorney upholding a patient’s wishes.

When a family is faced with the decision to withdraw care, it seems as if spirituality plays

a large role in their decision. This can help or hinder the request to withdraw care depending on

the beliefs of the patient’s family. Some families embrace their faith when their loved one is

dying and use it to help them cope. They will express that they believe their loved one will have

a better life after death and find comfort in their faith (Berger, Shuster, Van Roenn, 2006).

Others will state that because of their religious beliefs, they are not going to withdraw care and

they believe whether or not a patient dies is up to God. Families believe they are playing God or

forcing death by discontinuing medical care. Families will state they are leaving their loved ones

care in the hands of God and will continue aggressive care and whatever the outcome is, is what

God intended (Berger, Shuster, Van Roenn, 2006).

Catholicism has had much debate over the last few years about withdrawing care. Many

Catholics believe it is euthanasia to withdrawal care. After the Terri Schiavo case, many

Catholics felt the church needed to take a stance on withdrawing care. There have been several

documents released recently to guide Catholics when it comes to medical treatment and

withdrawing care. The Catholic religion differentiates between treatment and care. Treatment is

defined as medical interventions such as mechanical ventilation, surgery, or any procedures and

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medications aimed to prolong life. Care is defined as basic human rights and necessity such as

hydration and feeding (Shannon, Walter, 2005). They believe that food and water are not forms

of medical treatment because food and water by themselves cannot overcome disease or restore

health but are basic means of sustaining life (McHugh, 1990). The Catholic Church also states to

be careful not to assume that someone who lacks cognitive function and is unable to verbalize

their wishes has lost the ability to continue to pursue their spirituality (McHugh, 1990).

However, the church does recognize that in the unconscious and imminently dying patient,

nutrition and hydration are no longer of use to that patient and are a burden because the process

of dying has already begun. Nutrition and hydration can never be removed to hasten death. This

is considered euthanasia (McHugh, 1990). When it comes to withdrawing medical care, the

Catholic Church believes that care may be withdrawn if the patient has no “reasonable hope of

pursuing life’s purposes” (Shannon, Walter, 2005) and the medical intervention is a burden.

The Christian standpoint on withdrawing care is essentially the same as the Catholic

beliefs. Christians also believe that if death is inevitable and life prolonging treatments will not

benefit the patient, a family can choose to withdrawal care. Christianity also focuses on

hydration and nutrition. They too believe that hydration and nutrition are basic needs and to

remove such when it is not contraindicated or burdensome is euthanasia (Gill, 2006).

With the rise in the number of middle-eastern communities in the United States, it is also

important to be aware of religious beliefs outside of Christianity. The Islamic religion is one of

the top three religions in the world. The Islamic religion follows the guiding of the Quran.

Muslims believe that death is a rebirth into another world and therefore a gift that is given by

Allah (God) at the point in which he chooses (Zahedi, Larijani, Bazzaz, 2007). It is their belief

that saving a life is “one of the highest merits and imperatives in Islam” (Zahedi, Larijani,

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Bazzaz, 2007). Because of this, healthcare providers must do everything possible to save a

patient’s life. Withdrawing care in the Islamic religion is only allowed when a physician is

certain that death is inevitable and continued treatment would only prolong it (Zahedi, Larijani,

Bazzaz, 2007). They also believe that it is the job of the physician to make the patient

comfortable in death. However, the Quran states that pain is a form of test or trial used to

confirm a believer’s spirituality (Zahedi, Larijani, Bazzaz, 2007). It is believed that everyone

should have a taste of pain at the time of death as a payment for sinful behavior but that pain

medicine may still be administered until death.

Hinduism is also one of the top religions in the world. While, Hinduism isn’t as prevalent

in the United States, their religious beliefs are extremely important in their decision to withdraw

care. Hindus believe in a good and a bad death. A good death is one which is at the right time

and in the right place. In the Hindu religion, if a person cannot pass away on the banks of the

sacred Ganges, then the person passing lies on the floor of their own home with Ganges water

(blessed water) at their side to be placed on their lips during and after the dying process (Firth,

2005). A bad death is at the wrong place and time, a violent death, a premature death, and an

uncontrolled death (Firth, 2005). An uncontrolled death is one in which the family cannot

complete their rituals. Anytime death is accompanied by vomit, feces, and urine it is viewed as a

bad death. Hindus believe with a bad death, the soul is not free. A bad death is then followed by

bad luck, nightmares, illness, and infertility and they must spend the next seven generations

paying for it (Firth, 2005). Withdrawing care for the Hindu takes a clear understanding of the

patient’s prognosis. Hindus will allow a loved one to have care withdrawn once they understand

that death is inevitable and continuing care only burdens the patient. Once the decision to

withdraw care is made, it is extremely important to let Hindus perform their last rights on their

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loved one. This may include a bed on the floor, family presence to say their goodbyes, and

allowing the family to give their loved one Ganges water.

While spirituality and religion play a large role in a family’s decision to withdraw care,

race may play just as important of a role. In a study done at Duke University Hospital in the

cardiac care unit from 1998-2006, over one thousand deaths were reviewed to see if race had any

effect on the decision to withdraw care. Several ethnic groups were reviewed: Asian, Native

American, and Hispanic were all combined into one group (“other”) and whites and blacks were

individually represented. The study concluded that race does play a role in the decision to

withdraw care (Johnson, Newby, Granger, Cook, Peterson, Echols, Bride, 2010). Studies show

that blacks are less likely to receive medical intervention at the time of diagnosis but are more

likely to pursue aggressive care in end-of-life. Results showed that blacks are twice as likely to

have a full code status and to pursue aggressive care over whites. Blacks are half as likely as

whites to withdraw care and blacks are less likely to receive hospice or palliative care at the end

of their lives (Johnson, Newby, Granger, Cook, Peterson, Echols, Bride, 2010).

This same study also found that age is an influence on code status and withdrawing care.

As age increases, a patient is more likely to have do-not-resuscitate orders and to have care

withdrawn. The study implies that after the age of 65, patients are more likely to pursue limited

and comfort care in end-of-life situations. The same study also concludes that there is no

significant difference between men and women and the decision to withdrawal care (Johnson,

Newby, Granger, Cook, Peterson, Echols, Bride, 2010).

Once a decision has been made by the family to withdraw care, there are several options

the family can choose. For most ventilated patients in an intensive care setting, after the family

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has decided to withdraw care, the patient is removed from the ventilator. A patient is then made

comfort care status and will be given pain medication to decrease pain and aid with air hunger

during the dying process. Unless the patient lives for several days after being removed from the

ventilator, the patient and family will remain in the intensive care unit until the patient expires.

Some hospitals have a comfort care room where the patient is transferred and cared for until

passing. If the patient has not passed for a few days, the patient may be transferred to the medical

unit where the patient will continue to receive comfort care measures until passing. There is also

the option of hospice if the staff feels the patient will live long enough to need hospice care.

Most facilities have a palliative care team that will take over care and write orders once

the family has decided to withdraw care. Palliative care is given to relieve pain and ease stress

(Mosby, 2002). Palliative care and comfort care are used interchangeably in the hospital setting.

Palliative care is focused on symptom management. The palliative care team will meet with the

family and discuss the plan of care for the patient. They answer any questions the family may

have and educate the patient’s family on what to expect in the dying process. The palliative care

team will also talk to the families about their wishes and expectations as their loved one passes

(Palliative Care, 2011). If the patient transitions from the hospital to home, a skilled nursing

facility, or a hospice center, the designated hospice group used would then continue palliative

care for the patient and family.

The decision to withdraw care is not an easy one. It is filled with doubt and unease for

both the patient’s family and health care providers. Regardless of the tough decision to withdraw,

it is important as health care providers to understand the cultural, spiritual, race, or other related

factors that may influence a family’s decision. This will help make the patients and families

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experience an improved one and make it easier for the family to be at peace with the decision

they have made.

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References

Rosdahl, C.B., & Kowalski, M.T. (2008). Textbook of basic nursing. Lippincott, Williams &

Wilkins.

Gabrielli, A., Layon, A.J., Yu, M. (2008). Civetta, taylor, and kirby’s critical care. W.W. Norton

& Company.

Jonas (Ed.). (2005). Mosby’s dictionary of complementary and alternative medicine. Elsevier.

Mosby’s medical, nursing, & allied health dictionary (6th ed.). (2002). St. Louis, MO: Mosby’s

Inc.

Barclay, L. (2008, October 7). End-of-life discussions may reduce aggressive care in terminally

ill patients. Medscape Medical News. Retrieved April 2, 2011, from http://www.medscape.

org

Lachman, V.D. (2010). Ethics, law, and policy. Clinical ethics committees: organizational

support for ethical practice. Medsurg Nursing, 19(6), 351-3.

What is palliative care (n.d.). Retrieved April 2, 2011, from http://www.getpalliativecare.

org/whatis

Understanding CPR and DNR. (n.d). Retrieved April 2, 2011, from http://www.cancer.

net/patient/coping/End-of-Life+Care/Understanding+CPR+and+DNR

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Advanced Directives by state. (2011). Retrieved April 9, 2011, from http://www.noah-

health.org/en/rights/endoflife/adforms.html

Silveira, M.J., Kim, S.Y., Langa, K.M. (2010). Advanced directives and outcomes of surrogate

decision making before death. The New England Journal of Medicine, 362(13), 1211-8.

Berger, A.M., Shuster, J.L., Van Roenn, J.H. (2006). Principles and practice of palliative care

and supportive oncology. Lippincott Williams & Wilkins.

Shannon, T.A., Water, J.J. (2005). Assisted nutrition and hydration and the catholic tradition.

Theological Studies, 66(3), 651-63.

McHugh, J.T. (1990). Principles in regard to withholding or withdrawing artificially assisted

nutrition/hydration. Issues in Law & Medicine, 6(1), 89.

Gill, R. (2006). Health care and Christian ethics. Cambridge University Press.

Zahedi, F., Larijani, B., Bazzaz, J.T. (2007). End of life ethical issues and Islamic views. Iran J

Allergy Asthma Immunol, 6(5), 5-15.

Firth, S. (2005). End-of-life: a Hindu view. Lancet, 366, 682-86.

Johnson, R.W., Newby, L.K., Granger, C.B., Cook, W.A., Peterson, E.D., Echols, M. Bride, W.,

Granger, B.B. (2010). Differences in level of care at the end of life according to race.

American Journal of Critical Care, 19(4), 335-44.