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End of Life » Withdrawing or Withholding Treatment: Futility, Best interests and Unjustifiable Burdens

Guidelines and Policies

End of Life Care and Decision Making Guidelines [PDF] NSW
NSW Health
Guidelines set out a process of decision making in regards to end-of-life.

Guidelines for a Palliative Approach in Residential Aged Care Cth
NHMRC
The guidelines aim to provide support and guidance for the delivery of a palliative approach in residential aged care facilities across Australia. They cover all major aspects of providing a palliative approach for an RACF resident, from attending to physical symptoms (e.g. fatigue, dehydration) and spiritual needs to dealing with the reactions of family members.

Guidelines on Forgoing Life-Sustaining Medical Treatment
American Academy of Pediatrics

Post Coma Unresponsiveness (Vegetative State): A clinical frame work for diagnosis [PDF] Cth
NHMRC
Guidelines for assessment and diagnosis of Post-Coma Unresponsiveness.

Withholding and withdrawing life-prolonging medical treatment. Guidance for decision making UK
British Medical Association Ethics Committee
Comprehensive guidance on the controversial and emotive issue of withholding and withdrawing life-prolonging treatment from patients of all ages.

Legislation

Guardianship Act 1987 NSW
Arguably the Guardianship act allows the person responsible to refuse as well as to consent to medical treatment and to request the withdrawal of treatment.

Toolkits and Protocols

Better Palliative Care for older people [PDF]    International
WHO
Aimed at health policy- and decision-makers, this booklet presents the needs of older people, the different trajectories of illnesses they suffer, evidence of underassessment of pain and other symptoms, their need to be involved in decision-making, evidence for effective palliative care solutions, and issues for the future.

Futility
Ethics & Health Law News

Statement on withholding and withdrawing treatment [PDF]
Australian and New Zealand Intensive Care Society and College of Intensive Care Medicine of Australia and New Zealand.

Treatment and care towards the end of life: good practice in decision making UK
General Medical Council
Widely accepted comprehensive guidelines on end of life care. Useful format, extensive contents page with links to each section.

Withdrawal or Limitation of Treatment
University of Illinois College of Medicine

Withholding and withdrawing life-prolonging medical treatment: guidance for decision making
British Medical Association

Withholding and Withdrawing treatment
Care Search

Withholding or Withdrawal of Life-Sustaining Treatment
Children’s Bioethics Centre of the Royal Children’s Hospital (RCH) of Melbourne (Australia)

Cases

Airedale National Health Service Trust v Bland [1993] AC 789 UK
UK case that is often cited in Australian Courts. Regards a young man who has been in a persistent vegitative state with no prospect of recovery. Case concerned whether withdrawal of artificial feeding and other measures keeping Bland alive would constitute a criminal offence as the consent of the individual was not attainable. Contains a discussion on the need for consent and the ability of patients to refuse treatment.

Brightwater care group v Rossiter [2009] WASC 229 WA
Case where patient directed medical staff to discontinue provision of nutrition and general hydration. Court held that the patient had the right to determine whether they would receive treatment. General principles of palliative care looked at.

Commentary: R (on the Application of Burke) v General Medical Council
UK Clinical Ethics Network
Commentary on the case of R (On the Application of Burke) v General medical Council on futile treatment and the limits of the right to demand treatment. Find summaries of the case here.

Gardner; Re BWV [2003] VSC 173 Vic
A doctor may lawfully withold or withdraw treatment from a patient where it its futile to continue it or the patient has no hope of recovery. In this case the state appointed guardian requested the treatment be discontinued. In this case best interests of the patient and unjustifiable burden were considered.

Krommydas v Sydney West Area Health Service [2006] NSWSC 90 NSW
Court upheld the doctor’s view that treatment should be withdrawn despite relatives’ views to the contrary.

Neilsen v R (2001) 121 A Crim R 239 NSW
Held that failure to provide anti-psychotic medication for a schizophrenic patient could be a criminal offence.

Northridge v Central Sydney Area Health Service (2000) 50 NSWLR 549 NSW
A family member can apply for a review of a doctor’s decision to withdraw treatment. In this case that the diagnosis of futility was premature. Relatives views are not determinative.

R (Burke) v The General Medical Council [2006] QB 273 UK
There is no right to demand treatment in cases where the doctors will think it is futile.

Re KH (A child) [2012] EWHC B18 (Fam) UK
Application by an NHS Trust for declarations in relation to the best interests of a severely disabled child and, in particular, as to his medical treatment in the event that his condition should deteriorate. A declaration was made to authorise an advanced care plan to withdraw CPR, ventilation and antibiotics from a child severe brain damaged by viral encephalitis.

TS & DS v Sydney Children’s Hospital Network (“Mohammed’s case”) [2012] NSWSC 1609 NSW
Garling J refused to force doctors to provide mechanical ventilation when parents sought an order requiring treatment for their child. Garling J was highly critical of quality of life assessments. His Honour found that the treatment would not cure Mohammed, not prevent his inevitable death but it would cause significant pain and discomfort.

Papers, Reports and Books

A defence of the requirement to seek consent to withhold and withdraw futile treatments
Stewart C, (2012) 196(6) Medical Journal of Australia 406-8

Courts, Doctors and End of Life Care
Malcolm Fisher and Raymond Raper, (2005) 31 Intensive Care Medicine 762-764.
Discusses the UK Case of Burke v General Medical Council and the power of doctors to determine whether to withhold or withdraw treatment, even from a patient who is conscious and able to make their own decisions.

Knowing when to stop: futility in the ICU
Wilkinson, DJ and J Savulescu, (2011) 24(2) Current Opinion Anaesthesiol 160-5.

Medical futility in end-of-life care. Report of the Council on Ethical and Judicial affairs
(1999) 281(10) JAMA 937-941
Council on Ethical and Judicial Affairs, American Medical Association
The American Medical Association Council on Ethical and Judicial Affairs recommends a process-based approach to futility determinations. The process includes at least 4 steps aimed at deliberation and resolution including all involved parties, 2 steps aimed at securing alternatives in the case of irreconcilable differences, and a final step aimed at closure when all alternatives have been exhausted.

The consequences of noncompliance with guidelines for withholding or terminating resuscitation in traumatic cardiac arrest patients
Mollberg, NM, SR Wise, et al, (2011) 71(4) Journal of Trauma and Acute Care Surgery 997-1002.

The Messiha and Schiavo cases: third-party ethical and legal interventions in futile care disputes
Thomas Faunce and Cameron Stewart (2005) 183(5) Medical Journal of Australia 261-263.
Investigates situations where relatives demand treatment that is clinically judged to be futile, comparing US and Australian judicial approaches, asserting the need for ethics committee consultation to resolve disputes between doctor and relatives and the possibility of applying for judicial declarations of futility.

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