On the other hand, in the world of health, it is the lack of treatment that tends to generate more moral anxiety on the part of caregivers, despair for the patient, discord between family members and severe anxiety for the risk manager of the institution. There seems to be moral certainty to at least do something. And sometimes, even legislators and courts support this type of medical activism. The physician should ensure that family members understand the methods and goals of deep sedation and receive optimal support. Although the right of a competent and informed patient to refuse medical interventions has been firmly entrenched in bioethics and Anglo-American law for more than a decade,1 the role of patient consent in the refusal and interruption of end-of-life treatment and the ethical and legal status of patients` requests for treatment is less clear. In reviewing clinical guidance documents for end-of-life decision-making in clinical settings,2 we found an emerging consensus that there is no ethical difference between stopping and stopping treatment. However, the proposed standards varied with respect to the need for patient engagement. Most guides indicate that physicians are not obligated to offer treatments they deem unnecessary, but the notion of value-laden futility and the ambiguous meaning of patient autonomy suggest the need for further ethical analysis. But America`s top politician rejected that conclusion, insisting instead that « the distinction between assisted suicide and stopping life-sustaining treatment. is important and logical at the same time; It is certainly rational » [12]. To understand why the distinction is really valid, we must remember our conclusion, which we reached earlier: not all cases of a doctor`s remaining passive amount are negligible. The doctor had to not do what he was morally obligated to do. So, was he morally obligated to provide life-sustaining treatment? Reignier, J., Feral-Pierssens, AL., Boulain, T.
et al. Restraint and deprivation of life support in adults in emergency care: joint position paper of the Français intensive care medicine and the Français Society of Emergency Medicine. Ann. Intensivmedizin 9, 105 (2019). doi.org/10.1186/s13613-019-0579-7 Should patients (or their representatives) have decision-making authority and positive rights to desired interventions? A number of arguments can be put forward in support of this view. At first glance, patients have a stronger interest in the outcome of end-of-life decisions than physicians and should therefore have more authority. As Wreen5 notes, it`s living the patient`s life and dying to die. Concern for professional integrity cannot beat this when there is a possibility, however small, of survival, and the patient wants to seize it. Since assessments of benefits (and therefore harms) have an irreducibly subjective component, it is not necessarily a violation of integrity for physicians to perform desired medical interventions against their best clinical judgment. Refusing such interventions, as Biegler notes4, can indeed be harmful.
It is therefore incumbent upon the team to assess very carefully the specific purposes of Mr. Français` further treatment. Is the patient tired of living with his disabilities and is he no longer able to gather the mental energy necessary to adapt his life even more to even more limitations of his physical performance? Is he afraid of being held hostage on a ventilator for the rest of his life? Is he angry and upset about the disappointing outcome of the operation, but deep down, does he yearn for a few more years on this earth? Keywords APACHE , Autonomy , Basic life support , Charity , Brain death , Critical care medicine , Death , Permanent power of attorney , Ethics , Euthanasia , Justice , Law , Life support , Living wills , Non-malevolence , Patient preferences , Termination , Virtues , Vital function maintenance deprivation , Retention of vital functions Routine ICU admission does not improve survival or quality of life in elderly patients [24]. Retention or withdrawal decisions do not always result in the death of the patient. Self-care and frailty are key factors in decisions to limit treatment. The self-sufficiency classification system used in France to distinguish six levels of support for older persons (GIR) can assist in decision-making. Patients in Group 1, Footnote 1, who have the highest degree of dependence, are generally only entitled to comfort care, without life-sustaining interventions. Unless the cause of the life-threatening event can be easily and quickly reversed, patients with dementia classified in Group 2Footnote 2 should be treated in the same manner as patients in Group 1. Recent ethical discussions have raised serious doubts about the negative interpretation of patient autonomy and challenged the conventional wisdom that a positive interpretation of autonomy would essentially run counter to physician integrity.
For example, Biegler4 and Wreen5 both deny that physician integrity requires limiting patient autonomy to refusals, arguing that patient consent should be required for both restraint and termination of treatment at the end of life. According to Biegler4, while the fundamental point of the consent process is to improve patient autonomy and prevent harm, the consent process may be relevant to refusing a procedure rather than simply giving it. In addition, the consent process is more focused on the concept of positive freedom, as it provides options to patients and thus promotes choice.4 Biegler thus balances positive treatment choice with disclosure requirements and presentation of options, both of which are considered fundamental to physician integrity in therapeutic settings. From an ethical point of view, the two necessary conditions mentioned above for medical treatments also apply to the initiation and continuation of treatments. A health care provider must have both a medical indication and consent to begin treatment. Similarly, she may continue treatment only if and for as long as the treatment is still medically indicated and the patient continues to consent to the treatment. How can this be transferred to the field of life-sustaining medical interventions? Every time respirologist Dr. P. connects a patient to a ventilator, she takes moral responsibility for that decision and its consequences. Never mind that ventilation is a standard, if not routine, procedure that any pulmonologist would have initiated under the circumstances.
For example, if the patient is severely injured by ventilation, Dr. P. should feel bad about it. For example, if it becomes apparent that the patient refused ventilation, but Dr. P. imposed the treatment on the patient, she could be overwhelmed by battery charges. However, the situation is more complex when Dr. P. decides not to ventilate the patient. Now the question arises as to whether Dr.
P. was morally obligated to initiate ventilation. The gap between regulatory requirements and day-to-day reality is glaring. Most patients, even those with serious chronic illnesses, do not communicate their wishes in detail to their family or doctor, or write advance directives. For many patients, especially elderly nursing home residents, there is no plan for end-of-life decisions and palliative care. Therefore, when these patients experience life-threatening events, the decision to refuse or withdraw life-sustaining measures poses major challenges to emergency health professionals. The patient`s chief physician – if appointed – is rarely available for an emergency consultation. In addition, the establishment of a collegial decision-making process in line with legal requirements faces exceptional practical obstacles in the event of an emergency (including during preclinical treatment).