Fustinoni Osvaldo, Barone María Elisa, Elli José R, Gonorazky Sergio E, Martínez Perea María Del Carmen, Rotta Escalante Roberto
área Vascular y Comité de Docencia e Investigación, Instituto de Neurociencias Buenos Aires (INEBA), Argentina. E-mail:
Departamento Capacitación, Dirección Médica INCUCAI, Argentina.
Medicina (B Aires). 2020;80(1):48-53.
Patient relatives often request withdrawal of life support, especially artificial nutrition and hydration, in cases of permanent vegetative or minimally conscious state, and resort to court in case of disagreement. Two recent cases of withdrawal authorized by the courts concerned, one from abroad and one from Argentina, have been controversial. Although it may appear inhuman to stop feeding and hydrating such patients, to continue it only prolongs a state of irreversible biological subsistence. Families tend to increasingly accept withdrawal if the patient status remains unchanged. However, concern persists regarding the suffering that patients may undergo from onset of withdrawal till death, even though such suffering is little conceivable in the absence of cortical function and conscience content. While doctors and the layman consider ethical to withdraw life support, a nonnegligible proportion of doctors consider that vegetative state patients, even more minimally conscious state patients, do experience hunger, thirst and pain. In some countries, like the United Kingdom, strict withdrawal criteria were proposed, together with pharmacological treatment schemes for the distress arising during the withdrawal period, even though its benefit is controversial. In Argentina, two scientific societies have publicly advocated withdrawal, but not issued formal guidelines. In any case, both "dignified death" Law 26.742 and the Civil Code consent withdrawal of life support, if accompanied by appropriate relief of clinical symptoms indicating suffering.
在患者处于永久性植物状态或最低意识状态的情况下，患者亲属常常要求撤除生命支持，尤其是人工营养和水分供给，若存在分歧则诉诸法庭。最近两起经法院批准的撤除生命支持的案例引发了争议，其中一起来自国外，另一起来自阿根廷。虽然停止给这类患者喂食和补充水分看似不人道，但继续这样做只会延长不可逆转的生物生存状态。如果患者状况没有变化，家属往往越来越倾向于接受撤除生命支持。然而，对于患者从撤除生命支持开始到死亡可能遭受的痛苦，人们依然存在担忧，尽管在没有皮质功能和意识内容的情况下很难想象会有这样的痛苦。虽然医生和外行都认为撤除生命支持符合伦理，但仍有相当比例的医生认为，处于植物状态的患者，甚至是最低意识状态的患者，确实会经历饥饿、口渴和疼痛。在一些国家，如英国，提出了严格的撤除标准，以及针对撤除期间出现的痛苦的药物治疗方案，尽管其益处存在争议。在阿根廷，两个科学学会公开主张撤除生命支持，但未发布正式指南。无论如何，“尊严死亡”的第26.742号法律和《民法典》都同意在伴有适当缓解表明痛苦的临床症状的情况下撤除生命支持。
