Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI), Rome, Italy.
Department of Surgical Sciences, University of Turin, Turin, Italy.
Minerva Anestesiol. 2018 Jun;84(6):756-765. doi: 10.23736/S0375-9393.18.12299-1. Epub 2018 Jan 17.
In the last decades, mortality from severe acute illnesses has considerably declined thanks to the advances in intensive care medicine. Meanwhile, critical care physicians realized that life-sustaining treatments (LST) may not be appropriate for every patient, and end-of-life care in the Intensive Care Unit (ICU) started to receive growing attention. Most deaths occurring in the ICU now follow a decision to forgo life-sustaining treatments (DFLST), which can be implemented either by withdrawing (WDLST) or withholding (WHLST) life-sustaining treatments. Despite the broad consensus about the equivalence of the two practices from an ethical point of view, the issue of the best option between WDLST and WHLST constantly gives rise to controversies in clinical practice. This review is not intended to take a stand for or against WDLST or WHLST. Based on available evidence, the definitions of the two practices are first presented. Secondly, the preferences of ICU physicians towards WDLST and WHLST are examined. Finally, some arguments are offered outlining pros and cons of WDLST and WHLST, stressing that the clinician's attention should focus on an early and thorough recognition of patients in need of a DFLST, rather than on the theoretical strength and weakness of the two practices. This approach will enable physicians to make informed decisions on how to implement the limitation of LSTs, considering the patients' clinical conditions and preferences, the circumstances and needs of their families.
在过去的几十年中，由于重症监护医学的进步，严重急性疾病的死亡率大大降低。与此同时，重症监护医师意识到，生命维持治疗（LST）可能并不适合每个患者，重症监护病房（ICU）的临终关怀开始受到越来越多的关注。现在 ICU 中大多数死亡是由于决定放弃生命维持治疗（DFLST）引起的，可以通过撤机（WDLST）或停止治疗（WHLST）来实施。尽管从伦理角度来看，这两种做法在本质上是等同的，已经达成广泛共识，但在 WDLST 和 WHLST 之间选择最佳方案的问题在临床实践中经常引发争议。本综述的目的不是赞成或反对 WDLST 或 WHLST。基于现有证据，首先介绍了这两种做法的定义。其次，检查了 ICU 医师对 WDLST 和 WHLST 的偏好。最后，提出了一些论点，概述了 WDLST 和 WHLST 的优缺点，强调临床医生应关注早期全面识别需要 DFLST 的患者，而不是关注这两种做法的理论优势和劣势。这种方法将使医生能够根据患者的临床状况和偏好、其家属的情况和需求，就如何实施 LST 限制做出明智的决策。
