Pragmatic Process for Application of the Four Principles

The relief of suffering through sensitive and compassionate withholding or withdrawal of life support has become an essential component of the practice of critical care medicine. In one survey conducted between 1987 and 1993, deaths in the ICUs that followed the withdrawal of life support increased from 51% to 90% (4). 

There is a point where all would agree that intensive care has moved beyond the realm of beneficence, but there is a wide, gray area in which opinion is bound to differ. This transition from the need for restorative to the need for palliative care may be gradual or sudden and is often sensed by the nursing caregivers and relatives, before medical staff. 

If an intensivist is faced with a situation where intensive therapy has failed, thought should be given to limitation or withdrawal of that therapy, as futile treatment deprives the patient of a good death. 

Decisions on treatment limitation and withdrawal must be discussed with all medical and nonmedical health care providers directly involved in the patient s care. It is the intensivist s responsibility to be certain that a consensus exists. A judgment that a treatment is inadvisable can be made only after aU relevant viewpoints have been considered. Withdrawal or limitation of treatment should, where possible, be initiated with unanimous agreement of the clinical team and the family. 

therefore, imperative that such predicaments are handled with a sensitive and human touch. It is particularly important that a paternalistic approach is not adopted as this often inflames the situation. Insistence that treatment limitation decisions will be imposed and once documented will be irrevocable totally disregards the wishes of relatives and must be avoided. A suggested protocol for such situations is as follows  

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