Principles and guidelines

1. It is recognised that the efforts of the intensive
   care staff will be directed towards both the preservation
   of life and the relief of suffering and that these must
   at all times be kept in balance.
   
   
   
   
   
   
2. The technological ability to preserve life does not
   indicate a need or obligation to preserve or prolong life
   as a goal in its own right. There will be circumstances
   in the management of the terminally ill where the quality
   of life will be the prime consideration.
   
   
   
   
   
   
3. There is no ethical difference between withholding
   and withdrawing therapy. This being said it is clear that
   there may be significant emotional and attitudinal
   differences on the part of both carers and families
   between the two.
   
   
   
   
   
   
4. Where possible the patient should be involved in the
   decision making process. It is important to understand
   however that autonomy has limitations. The patient must,
   for instance, be of sufficient intellectual capability
   and emotional stability to meaningfully participate in
   the decision making process and must be able to
   communicate their wishes. It must be recognised that some
   patients in intensive care may appear competent but not
   rational. It is the opinion of some that only when normal
   function is restored can full autonomy be exercised.
   Furthermore, the patient or representative does not have
   the right to demand unlimited or futile therapy.
   
   
   
   
   
   
5. It must be recognised that even with optimal care and
   the best intention some critically ill patients suffer
   pain and discomfort. This fact should always be a part of
   the discourse and must be weighed against the probability
   of a good outcome. A good outcome should be judged both
   in terms of length and quality of survival after
   intensive care treatment. This is a dynamic that varies
   from patient to patient and from day to day.
   
   
   
   
   
   
6. The weight of responsibility for the decision to
   terminate life support should be borne by intensive care
   staff in conjunction with the admitting team. The issues
   should be clearly communicated to and canvassed with all
   those who have significant involvement in patient care.
   
   
   
   
   
   
7. Despite the fact that, in general, the lay person
   will not have the background to understand the complex
   medical, ethical and conceptual issues involved, we are of
   the belief that family support should be sought before
   active measures are withdrawn. It is desirable to avoid
   the full weight of the decision making process falling to
   the family, therefore consensus and agreement should be
   sought rather than permission asked.
   
   
   
   
   
   
   
   Given the hazy legal background that exists in relation
   to these issues it would be extremely difficult, indeed
   inadvisable, to withdraw therapy in the face of united,
   unremitting and unequivocal family opposition. In this
   situation, wider ethical consultation is recommended.
   
   
   
   
   
   
8. Where conflict exists within the family every effort
   should be made to mediate between the parties and achieve
   agreement. Failing this, priority must be ultimately
   given to the legal next-of-kin.
   
   
   
   
   
   
9. The sense of all discussions with family related to
   issues of cessation of life support should be clearly
   documented in the case record. Verbatim quotation may
   form an important part of this record.
   
   
   
   
   
   
10. The context and sense of a living will must always be
    considered and may take priority over its literal
    meaning. Under certain laws the existence of a living
    will may be seen as constraining the actions of intensive
    care staff. In this situation legal advice may need to be
    obtained.
    
    
    
    
    
    
11. Guidelines for no CPR orders are to be in accordance
    with the hospital policy, ie.:
    
    
    
    
    
    
    a) A No-CPR order should always involve appropriate
    members of the health care team (eg. nurses, allied
    health professionals, medical staff) in the decision
    making, although the final decision remains the
    responsibility of the senior attending medical
    officer.
    
    
    
    
    
    
    b) A No-CPR order should be recorded as a formal order in
    the patient's progress notes in a clear and unambiguous
    manner.
    
    
    
    
    
    
    c) A No-CPR order should incorporate a brief description
    of discussion with the patient and/or family members,
    and:-
    
    
    
    
    
    i) a statement of the patient's wishes (when the patient
    is competent), or
    
    
    
    
    
    ii) the role of the family/surrogate (when the patient is
    incompetent)
    
    
    
    
    
    d) Where a decision has been made NOT to involve a
    patient or surrogate in decisions regarding resuscitation
    status, an explanation should be provided in the progress
    notes as to the rationale underlying this decision.
    
    
    
    
    
    e) Any No-CPR order should include a statement of the
    medical condition to justify a No-CPR order.
    
    
    
    
    
    f) Any No-CPR order should include a statement about the
    scope of the order, specifying the management plan
    (curative and/or palliative) subsequent to the No-CPR
    order.
    
    
    
    
    
    g) Any No-CPR order should be subject to review of a
    regular basis and can be rescinded at any time. Any
    review should be implemented and documented in the
    patient's progress notes in the manner specified above.
    
    
    
    
    
    
12. The intensive care team should respect the cultural,
    philosophical and religious values of the patient and
    family. Appropriate spiritual counselling and moral
    support should be available to the patient and family and
    staff.
    
    
    
    
    
    
13. In the event where brain death has occurred, it is
    ethical to support corporeal functions while the question
    of organ donation is investigated. If consent is given it
    is ethical to support corporeal functions until organ
    removal. The interests of the transplant team are at all
    times to be considered secondary to the interests of the
    patient and family.
    
    
    
    
    
    
14. Management of the dying process is active. The goals
    are to provide dignity and relief of suffering to the
    patient and family. In practical terms the following
    guidelines are offered:
    
    
    a) All observations, monitoring, procedures and routine
    care, both medical and nursing that are not directed
    towards the comfort of the patient are withdrawn.
    
    
    b) Drug therapy is provided as required to relieve pain
    and distress.
    
    
    c) The patient may or may not be left on the ventilator
    at this time, and if so inspired oxygen concentration is
    reduced to that of air. Extubation should be considered
    in some cases.
    
    
    d) Supportive therapy should be withdrawn in a manner
    whereby a single action is not followed by immediate
    demise.
    
    
    e) Privacy and respect for the patient and family are to
    be accorded at this time. Transfer to the ward is
    discouraged but not proscribed.
    
    
    f) The family should be allowed to make their own
    decisions about whether they wish to remain with the
    dying patient or view the body after death.
    
    
    
    
    
    
15. The physician has an obligation to maintain
    communication with the family. The family should be given
    the opportunity to contact the physician after the
    patient has died if there are unanswered questions or
    problems related to the bereavement.
    
    
    
    

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