(Philadelphia, PA) - Critical care physicians with the University of Pennsylvania Health System address a newly-emerging ethical dilemma in medicine - what should health care professionals do when faced with a request from a patient to end the use of life-sustaining supplemental oxygen? Scott Halpern, MD, PhD, a fellow in the Division of Pulmonary, Allergy and Critical Care Medicine and senior fellow with the Center for Bioethics at Penn, along with John Hansen-Flaschen, MD, chief of the Division of Pulmonary, Allergy and Critical Care Medicine at Penn, have co-authored a guide for physicians faced with such requests. The commentary - which examines concerns physicians may have in removing such a minimally invasive and potentially palliative therapy, and suggests strategies for physicians to overcome them -- is in the September 20th issue of JAMA, the Journal of the American Medical Association.
Halpern explains, “Informed patients with decision-making capacity have well-established rights to forgo any and all forms of life-sustaining therapy. However, there is no clear definition of what constitutes a life-sustaining therapy. We tend to think of invasive medical therapies such as mechanical ventilation, kidney dialysis or tube feeding. When administered by face mask or nasal prongs, high flow oxygen is not at all invasive, yet it clearly serves a life-sustaining role for an increasing number of patients with advanced lung, heart, or cancer-related diseases. Many of these patients would lose consciousness and die within hours or even minutes if their supplemental oxygen was withdrawn.”
Advances in medicine have made it so that many more patients with end-stage diseases are living longer, and now the technology is available to provide high flow supplemental oxygen both in the hospital and at home, often providing a limited quality of life for patients. “So this is yet another ethical dilemma in medicine born of technological advancements,” adds Halpern.
Both Halpern and Hansen-Flaschen have received requests from patients to stop their flow of supplemental oxygen, resulting in death. Halpern first grappled with the difficulty of withdrawing oxygen from an awake and alert patient when, as a first year medical resident, he was treating a hospitalized patient suffering from advanced lung disease and cancer. One morning, the patient said he’d “had enough” and tugged on his mask but was too weak to remove it and asked for Halpern’s help to do so. Halpern debated this request with the attending physician who was concerned that the patient would experience air hunger and fear after oxygen was removed, necessitating high doses of sedating drugs. He worried this might constitute a form of euthanasia.
Hansen-Flaschen received a similar request from an outpatient who suffered from an advanced lung disease and was living at home. He could no longer get out of bed and his quality of life had seriously deteriorated. The patient wanted to stop his oxygen therapy and asked Hansen-Flaschen to help him avoid a sense of suffocation afterwards. “I had to ask myself, is this participating in a patient’s death or is it simply respecting a patient’s request? Plus, there’s no way to predict an individual’s response to removing supplemental oxygen and how much they will suffer.”
Hansen-Flaschen notes “Two-thirds of critical care patients in this country are cared for by general physicians or others without special training in critical care.” In light of this, Halpern said he hoped that this commentary “will provide a place for physicians to turn when faced with this particular dilemma. We hope that our recommendations may allow physicians to heed requests for the withdrawal of life-sustaining oxygen as readily as they may heed requests for the withdrawal of other life-sustaining therapies, such as mechanical ventilation and dialysis.”
The commentary addresses specific concerns physicians may have about withdrawing oxygen, including how to balance the burdens and benefits of supplemental oxygen; whether withdrawing oxygen might appear neglectful; how to determine whether patients retain decision-making capacity; when it is acceptable to use sedation in lieu of oxygen; and concerns about patients’ motivations for discontinuing oxygen.
Halpern and Hansen-Flaschen offer this four-step approach to help physicians overcome these concerns:
- Physicians should assure themselves, and other health care professionals involved in the patient’s care, as well as the patient’s family members and close friends that supplemental oxygen is a form of life-sustaining medical treatment. As such, requests to discontinue oxygen should be honored with the same judiciousness as requests to withdraw other forms of life support.
- Physicians should ensure that patients requesting the terminal withdrawal of oxygen are free from undue influences, including family member’s wishes, economic considerations or treatable depression.
- Physicians should ensure that the patient has the capacity to make medical decisions by documenting that patients show consistency, understanding, and rationality in making such requests.
- Physicians should ensure that patients and their family members understand the difficulty of predicting patients’ experiences after oxygen withdrawal.
This commentary is in the September 20th issue of Journal of the American Medical Association. The article is titled “Terminal Withdrawal of Life-Sustaining Supplemental Oxygen.”
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