Ethical and practical considerations of withdrawal of treatment in the intensive care unit

Purpose: To discuss the medical, ethical and legal basis of decisions to di scontinue life-support therapy in the adult intensive care unit (ICU), and to provide practical guidelines for the discontinuation of life support the rapy. Source: Relevant articles were retrieved through Medline (1991-present; ter ms: ethics, life support discontinuation, double effect, beneficence, non-m aleficence). Other sources include legal references, and personal files. Principal Findings: Understanding the legal and ethical principles of auton omy, beneficence, non-maleficence and double effect are crucial when withdr awing life support therapy. The law respects a competent patient's right to direct his/her healthcare but does not uphold his/her right to demand futi le care, Surrogate decision makers can be used when the patient is incompet ent, provided they are acting in the patient's best interest. Euthanasia is illegal and the distinction between discontinuation of therapy and euthana sia is legally clear. Skilful administration of palliative therapy cannot b e construed as euthanasia when the aforementioned ethical principals are re spected. The various practical methods of discontinuing therapy are discuss ed. Every ICU should develop its own guidelines and a checklist to help car egivers during this difficult time, Caregivers must anticipate the mechanis m of death and direct interventions at the symptoms that are likely to caus e discomfort. Drugs and dosages must be individualized, and depend on the u nderlying disease, anticipated mechanism of death, and the patient's pharma cological history. When prescribing a drug, the intention should be clear. Conclusions: Appropriate discontinuation of therapy in the ICU allows patie nts a dignified and comfortable death.