Neumann Peter
Fachbereich Klinische Anästhesiologie am Evangelischen Krankenhaus Göttingen-Weende.
Anasthesiol Intensivmed Notfallmed Schmerzther. 2009 May;44(5):380-4. doi: 10.1055/s-0029-1224785. Epub 2009 May 13.
To make a decision concerning the withholding and/or withdrawing of therapy is one of the most difficult tasks in medical care. Similar to other treatment decisions, initiation and interruption of therapy should be guided by the medical indication and, in principle, requires informed patient consent even during end-of-life care. However, especially in this situation, patients are frequently not able to give informed consent or to clearly express their wishes regarding therapy. Therefore, in Germany it is widely recommended to draft a "living will" in order to document the concerned individual's wishes for medical treatment either in general or for specific situations in the case of legal incompetency. Unfortunately, typical phrases of living wills such as "for the case that I am in the terminal stage of an incurable, lethal disease, I hereby wish that..." often do not exactly match the patient's situation or leave the medical team with the difficult task of precisely predicting the prognosis of an individual patient. However, according to a retrospective analysis of two large databases, even sophisticated scoring systems predicted a survival of more than two months in approximately 50% of the patients at one week before their actual deaths and again in 15% of the patients at 24 hours before their deaths. These data emphasise the fact that it is almost impossible to precisely forecast the individual prognosis of terminally or critically ill patients. Consequently, the careful but invariable subjective appraisal of the patient's prognosis and the applicability of the living will by the medical team is of major importance for the decision to withhold or withdraw therapy. Most often, this decision is the result of a cumbersome and controversial debate within the medical team. If a formal living will or any other declaration of the patient's will regarding medical care is lacking, the medical team faces the challenge to explore the patient's putative will by questioning his/her friends and relatives. In order to reach a unanimous decision with relatives and also within the medical team, it may be helpful as a first step to withhold an escalation of therapy for a limited time, while daily reassessing the situation, before it is actively reduced. In Germany, health-care professionals do not always feel certain about the question of whether an active reduction of medical therapy is, in fact, active or passive euthanasia. The German Federal Court of Justice, however, has explicitly stated that withholding and withdrawing therapy is passive euthanasia and as such is legal.
决定停止和/或撤销治疗是医疗护理中最困难的任务之一。与其他治疗决策类似，治疗的开始和中断应以医学指征为指导，原则上即使在临终护理期间也需要患者的知情同意。然而，特别是在这种情况下，患者往往无法给出知情同意或清楚表达他们对治疗的意愿。因此，在德国，人们广泛建议起草一份“生前遗嘱”，以便记录相关个人在丧失法律行为能力时对一般医疗或特定情况的医疗意愿。不幸的是，生前遗嘱中的典型表述，如“如果我处于无法治愈的致命疾病的终末期，我在此希望……”，往往与患者的情况不完全相符，或者给医疗团队留下精确预测个体患者预后的艰巨任务。然而，根据对两个大型数据库的回顾性分析，即使是复杂的评分系统，在患者实际死亡前一周，仍有约50%的患者被预测存活超过两个月，在死亡前24小时，仍有15%的患者被如此预测。这些数据强调了一个事实，即几乎不可能精确预测晚期或重症患者的个体预后。因此，医疗团队对患者预后的谨慎但始终主观的评估以及生前遗嘱的适用性，对于决定停止或撤销治疗至关重要。大多数情况下，这一决定是医疗团队内部繁琐且有争议的辩论的结果。如果缺乏正式的生前遗嘱或患者关于医疗护理的任何其他意愿声明，医疗团队面临着通过询问患者的朋友和亲属来探究患者假定意愿的挑战。为了与亲属以及医疗团队内部达成一致决定，作为第一步，在积极减少治疗之前，可能有助于在有限的时间内暂停治疗升级，同时每天重新评估情况。在德国，医疗保健专业人员对于积极减少医疗治疗实际上是否属于主动或被动安乐死的问题并不总是确定。然而，德国联邦法院已明确表示，停止和撤销治疗是被动安乐死，因此是合法的。
