ASSESSMENT AND MANAGEMENT OF MEDICALLY ILL PATIENTS WHO REFUSE LIFE-PROLONGING TREATMENTS - 2 CASE-REPORTS AND PROPOSED GUIDELINES

Patients who have chosen to have treatment withdrawn because of debili tating conditions pose a special problem for palliative care. We repor t on two such patients: patient 1 refused amputation of a gangrenous l eg and patient 2 refused food and hydration after a series of strokes. The management of these patients through the dying process is discuss ed and guidelines are suggested. The criteria for competency include b oth a general cognitive and psychiatric assessment as well as a specif ic evaluation of the patient's ability to make the treatment withdrawa l decision. Treatable symptoms which impair the patient's quality of l ife and have an impact on the decision should be corrected. If a proxy decides to withdraw therapy in an incompetent patient, this decision should accord with the patient's known wishes and values as far as pos sible. The beneficence of the decision may be assessed according to th e disease process, degree of suffering, and risks of accepting treatme nt. The complexity of these cases calls for a multidisciplinary approa ch, and the palliative care team should work in collaboration with the primary care treatment team.