BACKGROUND
As life-sustaining therapies have emerged, so have the ethical and legal discussions about the appropriate use of these treatments. Decisions around withholding and/or withdrawing these therapies are often central in end-of-life decision making. In 1983, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research published Deciding to Forgo Life-Sustaining Treatment.1 This document still stands as the cornerstone for ethical decisions relating to withholding and withdrawing therapies in current practice. Tenets from the President's Commission report include the following:
* The voluntary and informed choice of a competent patient should determine whether a life-sustaining therapy would be undertaken.
* Healthcare professionals serve the patient's best interest by maintaining a presumption in favor of sustaining life while recognizing that competent patients are entitled to choose to forgo any treatments, including those that sustain life.
* Whether a treatment is warranted depends on the balance of its usefulness or benefits for a particular patient and consideration of the burdens that the treatment would impose.
* An appropriate surrogate, ordinarily a family member, should be named to make decisions for patients who have insufficient capacity to make their own decisions.
The American Nurses Association, in its preamble of the Code for Nurses, states that when "making clinical judgments, nurses base their decisions on consideration of consequences and of universal moral principles, both of which prescribe and justify nursing actions. The most fundamental principle is respect for persons."2 Respect for persons is a fundamental principle of bioethics; ensuring respect for persons includes honoring their wishes regarding treatment decisions.
POSITION STATEMENT
This is the position of the HPNA Board of Directors:
* Every person with decision-making capacity has the right to initiate any medical therapy that offers reasonable probability of benefit and to withhold and/or withdraw any medical therapy.
* Patients have the right to appoint a surrogate decision maker.
* It is the duty of the healthcare team to honor any previously communicated advance directive, including those that appoint a surrogate decision maker if the patient loses decision-making capacity.
* Patients who lack decisional capacity and who do not have a previously designated surrogate decision maker should have one named in accordance to state, local, and institutional regulations.
* Parents/guardians have legal authority to make decisions regarding treatment for their children if the patient is younger than 18 years, and they are considered to have their child's best interest at heart.
* All life-sustaining therapies may be withheld or withdrawn.
* Palliative care nurses shall assist as needed to facilitate decision making and advocate care that is consistent with the stated wishes of the patient and his/her surrogates.
DEFINITION OF TERMS
Forgoing life-sustaining treatment. To do without a medical intervention that would be expected to extend the patient's life. Forgoing includes withholding (noninitiation) and withdrawing (stopping).
Life-sustaining therapies include but are not limited to cardiopulmonary resuscitation, cardiac support devices (pacemakers, internal cardioverters/defibrillators, intraaortic balloon pumps) and cardiac medications, respiratory support devices (invasive and noninvasive mechanical ventilation, oxygen, and respiratory medications), renal support devices (dialysis in any form) andrenal medications, blood products, parenteral and enteral nutrition and hydration, cancer treatments, and surgery.
Approved by the HPNA Board of Directors July 2008.
Developed by:
Peg Nelson, MSN, APRN, BC-PCM
Meg Campbell, PhD, RN, FAAN
Maureen Lynch, RN, NP, MS, CS
Christy Torkildson, RN, MSN, PHN
This position statement reflects the bioethics standards or best available clinical evidence at the time of writing or revisions.
To obtain copies of HPNA Position Statements, contact the National Office at:
One Penn Center West, Suite 229, Pittsburgh, PA 15276-0100
Phone: (412) 787-9301
Fax: (412) 787-9305
Web site:http://www.HPNA.org
References