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Commentary
Withdrawal of life-sustaining therapy: the case for delay
  1. Bernard A Foëx
  1. Correspondence to Bernard A Foëx, Emergency Department, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; bernard.foex{at}cmft.nhs.uk

https://doi.org/10.1136/emermed-2016-206397

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    To everything there is a season …When should life-sustaining treatment (LST) be stopped? The simple answer is when it is no longer appropriate to continue. This may be when the patient withdraws consent for treatment to continue, or when further treatment becomes futile.

    But what is futility? “I know it when I see it”, as Supreme Court justice Potter Stewart said in 1964 (in relation to something quite different). In some cases it is indeed easy to recognise. A definition may be more challenging. A treatment may be said to be futile when it will not achieve its stated aim either qualitatively or quantitatively.1 An example of qualitative futility is giving antibiotics for a viral infection. Quantitative futility is, for example, giving ever-increasing doses of norepinephrine to a patient with multiorgan failure, who remains hypotensive and whose lactate is increasing. Quantitative futility has also been defined as a treatment, which has a less than 1 in a 100 chance of success.1

    In the case discussed by Gardiner et al2 in this journal (ref) there are several rationales for not stopping LST early, namely,

    1. Prognostic uncertainty

    2. Brainstem testing as a diagnostic end point

    3. Respect for autonomy

    4. Utilitarianism (maximising the good)

    Each of these deserves some explanation.

    Prognostic uncertainty

    It is difficult to make predictions, especially about the futurei

    The Neurocritical Care Society (NCS) has recommended defining a devastating brain injury (DBI) as, ‘neurological injury where there is an immediate threat to life from a neurological cause’, and, ‘severe neurological insult where early …

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    Footnotes

    • Competing interests None declared.

    • Provenance and peer review Commissioned; internally peer reviewed.

    • ↵i Quotation variously attributed to Niels Bohr, Sam Goldwyn, Robert Storm Petersen, Mark Twain, Yogi Berra, and probably others.

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