Withholding and withdrawal of life support: ethical, legal, and clinical aspects.

The withholding and withdrawal of life support are processes by which various medical interventions either are not given to or are taken away from patients, with the expectation that they will die as a result. The propriety of withholding and withdrawal of life support has been supported by ethical statements from groups such as the Task Force on Ethics of the Society of Critical Care Medicine, and by a series of legal decisions beginning with the Quinlan case. Surveys of healthcare professionals indicate that most ICU physicians withhold and withdraw life support on a regular basis, that they consider these processes ethically equivalent, that they recommend withholding and withdrawal of life support based upon prognosis (which may be expressed as futility), and that they consider patient and surrogate wishes to be most important in deciding to forego life-sustaining treatment, but place these wishes in the context of their own assessment of prognosis. Observational studies show that: withholding and withdrawal of life support occur frequently, the frequency has increased over the past several years in some ICUs, patients and families generally agree with physician recommendations to limit care or request such limitation, disagreements sometimes occur on this issue, withdrawal of life support occurs more commonly than withholding of life support in most ICUs, cardiopulmonary resuscitation is the therapy most frequently withheld, mechanical ventilation is the therapy most frequently withdrawn, this withdrawal process usually is gradual, and it usually is facilitated by the administration of sedatives and analgesics. Clinical information such as this is helping to define a standard of care in the area of withholding and withdrawal of life support.