Position statement of the Brazilian Palliative Care Academy on withdrawing and withholding life-sustaining interventions in the context of palliative care

Vidal, Edison Iglesias de Oliveira; Ribeiro, Sabrina Correa da Costa; Kovacs, Maria Júlia; Máximo da Silva, Luciano; Sacardo, Daniele Pompei; Iglesias, Simone Brasil de Oliveira; Silva, Josimário João da; Neves, Cinara Carneiro; Ribeiro, Diego Lima; Lopes, Fernanda Gomes

doi:10.62675/2965-2774.20240021-en

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Guidelines and Consensus • Crit. Care Sci. 36 • 2024 • https://doi.org/10.62675/2965-2774.20240021-en linkcopy

Position statement of the Brazilian Palliative Care Academy on withdrawing and withholding life-sustaining interventions in the context of palliative care

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The issue of withrawing and withholding life-sustaining interventions is an important source of controversy among healthcare professionals caring for patients with serious illnesses. Misguided decisions, both in terms of the introduction/maintenance and the withdrawal/withholding of these measures, represent a source of avoidable suffering for patients, their loved ones, and healthcare professionals. This document represents the position statement of the Bioethics Committee of the Brazilian Palliative Care Academy on this issue and establishes seven principles to guide, from a bioethical perspective, the approach to situations related to this topic in the context of palliative care in Brazil. The position statement establishes the equivalence between the withdrawal and withholding of life-sustaining interventions and the inadequacy related to initiating or maintaining such measures in contexts where they are in disagreement with the values and care goals defined together with patients and their families. Additionally, the position statement distinguishes strictly futile treatments from potentially inappropriate treatments and elucidates their critical implications for the appropriateness of the medical decision-making process in this context. Finally, we address the issue of conscientious objection and its limits, determine that the ethical commitment to the relief of suffering should not be influenced by the decision to employ or not employ life-sustaining interventions and warn against the use of language that causes patients/families to believe that only one of the available options related to the use or nonuse of these interventions will enable the relief of suffering.

Keywords:
Palliative care; Withholding treatment; Clinical decision-making; Bioethics; Ethics, medical; Consensus

Examples of strictly futile treatments	Rationale
Initiating cardiopulmonary resuscitation procedures in a patient with cardiac arrest due to refractory hypotension from septic shock despite the best possible circulatory support	In these situations, cardiopulmonary resuscitation procedures will not be able to address the problem of refractory hypotension that caused cardiac arrest, and the physiological goal of reestablishing spontaneous circulation is not feasible
Initiating cardiopulmonary resuscitation procedures in a patient with cardiac arrest due to refractory hypoxia despite the best possible ventilatory support	In these situations, cardiopulmonary resuscitation procedures will not be able to address the problem of refractory hypoxia that caused cardiac arrest, and the physiological goal of reestablishing spontaneous circulation is not feasible
Prescribing of antifungal medication for patients with staphylococcal sepsis without clinical or laboratory evidence of fungal infection	There is no pathophysiological basis to justify this treatment and no possibility of the treatment achieving the physiological goal of treating the patient's infection
Cardiopulmonary resuscitation procedures in patients with rigor or livor mortis in the absence of severe hypothermia as a cause of cardiac arrest	In the absence of severe hypothermia, rigor and livor mortis are clinical signs of irreversible death and usually indicate that more than 1 hour has elapsed since the interruption of spontaneous circulation, with no possibility of recovery(³⁵,³⁶)
Maintaining cardiopulmonary resuscitation procedures for more than 30 minutes for patients with asystole or refractory pulseless electrical activity, who have already received hight-quality resuscitation efforts and whose potentially reversible causes have already been addressed to the extent possible in the given care context	In the absence of new elements indicating that cardiopulmonary resuscitation procedures, which have been extensively attempted and failed to restore spontaneous circulation, could become successful, their continuation alone will not be able to achieve the physiological goal of restoring spontaneous circulation

Examples of potentially inappropriate treatments	Rationale
Use of tube feeding for patients with advanced dementia	On the one hand, there is evidence suggesting that artificial feeding in patients with advanced dementia does not increase their probability of survival and is associated with a greater likelihood of adverse events, such as pressure sores and use of physical restraints, than comfort feeding.(⁷) On the other hand, the physiological goal of providing calories and nutrients can be achieved through these interventions. Additionally, it is important to consider that individuals with different cultural perspectives may have distinct frameworks for weighing the risks and benefits of tube feeding
Implementation of mechanical ventilation for patients with metastatic cancer	The presence of metastatic cancer, by itself, does not prevent the physiological goal of mechanical ventilation (e.g., reducing hypoxemia or hypercarbia). In certain contexts, mechanical ventilation may increase the patient's lifespan and enable them to achieve personal goals (e.g., attending the graduation of a grandchild). In other circumstances, the context and culture of the patient may interpret such a procedure as an "undue prolongation of dying"
Use of antibiotics for the treatment of recurrent aspiration pneumonia in a bedridden patient with severe sequelae of stroke	Except in cases of extremely multidrug-resistant germs for which no antimicrobial options are available, in general, there is the possibility that such agents will achieve their physiological goal of eliminating the bacteria responsible for the patient's infection. The appropriateness of continuing to prescribe antibiotics for these infections should take into account the extent to which the patient would like to be kept alive in their current state of health or would consider such a state as a condition worse than death, something closely related to their personal values
Initiating hemodialysis for patients in a chronic vegetative state	The chronic vegetative state alone does not prevent hemodialysis from achieving its physiological goal of purifying the patient's blood of substances that would usually be removed by kidney function, if it were preserved. The central issue here involves a value judgment on the risk/cost benefit ratio of introducing such a procedure for patients with minimal probabilities of regaining consciousness and/or functionality

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Associação de Medicina Intensiva Brasileira - AMIB Rua Arminda, 93 - 7º andar - Vila Olímpia, CEP: 04545-100, Tel.: +55 (11) 5089-2642 - São Paulo - SP - Brazil
E-mail: ccs@amib.org.br

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