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Wise Counsel

September 13, 1987

Useful guidelines for making those anguished decisions on withholding or withdrawing life-sustaining supports for terminally ill patients have emerged from a 2 1/2-year study by national experts under auspices of the Hastings Center in New York.

The new study makes a clear distinction between, on the one hand, suicide and mercy killing, which "our society properly forbids," and the refusal of life-sustaining treatment in certain circumstances, which is gaining wider and wider support. That is helpful, for some critics have complicated matters by failing to distinguish between efforts to prolong life and applications of medical technology that serve primarily to prolong dying.

The report emphasizes the right of the patient, or the patient's surrogate, to make the decisions regarding life-sustaining interventions, including food and water. This points to the importance of anticipating crises through a living will to make specific provision for deciding when to refuse life-sustaining treatment. The most difficult situations arise when a patient is no longer competent to make a decision and has no surrogate.

In discussing treatment, the report brings a fresh perspective by underscoring the importance of consent. Consent is required for bodily invasion, including "all forms of artificial nutrition and hydration, including nasogastric tubes and intravenous lines." The panel also argues that the patient or surrogate "should be able to forgo antibiotics and other life-sustaining medication," noting that "the burdens of such medication sometimes outweigh the benefits from the patient's perspective."

Appropriate palliative care and pain relief must be provided, the report asserts. "It is ethically acceptable to sedate a patient to the point of unconsciousness, even if the subsequent respiratory depression may lead to an earlier death, as long as the patient or surrogate consents, this course serves the patient best, and the purpose is not to hasten death but to alleviate the patient's pain and suffering," the panel adds.

The report calls on health-care professionals to declare a patient dead when that patient is "dead by neurological criteria in a state that recognizes brain death," and not to seek family consent in such circumstances.

Decisions on refusing life-sustaining treatment never are easy. But the work of this committee will facilitate that painful process, and thus contribute to more effective and more compassionate use of medical resources.

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