Henig N R, Faul J L, Raffin T A
Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California 94305, USA.
Annu Rev Med. 2001;52:79-92. doi: 10.1146/annurev.med.52.1.79.
It is common for health care providers to deal with the complex and difficult issue of withdrawing advanced life support. The patient is always the key source of authority in these decisions. The most important ingredient in end-of-life decision making is effective communication. It is important to try to ascertain what the patient thought about quality-of-life values before surrogate decisions can be made on the patient's behalf. The concepts of beneficence, nonmaleficence, autonomy, and justice are the foundation of ethical decision making. Numerous legal precedents have laid the groundwork for end-of-life decision making. Most state courts have supported withholding and withdrawing life support from patients who will not regain a reasonable quality of life. The recent Patient Self-Determination Act encourages patients to fill out advance directives that state their desires. When continued intensive care is futile, advanced life support should be withdrawn. However, a narrow definition of futility in this situation is the key, since the concept of futility could lead to inappropriate decisions. It is best to consider a situation futile when the patient is terminally ill, the condition is irreversible, and death is imminent. During the withdrawal of advanced life support, terminal or rapid weaning is preferable to extubation. Combinations of opiates, benzodiazepines, and other agents help provide comfort to patients who are suffering.
医疗保健提供者处理撤除高级生命支持这一复杂且困难的问题是很常见的。在这些决策中，患者始终是关键的权威来源。临终决策中最重要的因素是有效的沟通。在代表患者做出替代决策之前，试图确定患者对生活质量价值观的看法很重要。行善、不伤害、自主和公正的概念是伦理决策的基础。众多法律先例为临终决策奠定了基础。大多数州法院都支持对无法恢复合理生活质量的患者停止和撤除生命支持。最近的《患者自主决定法》鼓励患者填写预先指示，阐明他们的愿望。当继续进行重症监护毫无意义时，应撤除高级生命支持。然而，在这种情况下，对“无意义”进行狭义定义是关键，因为“无意义”的概念可能导致不恰当的决策。当患者身患绝症、病情不可逆转且死亡即将来临的时候，最好将这种情况视为无意义。在撤除高级生命支持期间，终末期或快速撤机比拔管更可取。阿片类药物、苯二氮䓬类药物和其他药物的联合使用有助于为正在受苦的患者提供舒适感。
