Chinese Society of Critical Care Medicine-CSCCM 10th Anniversary

讲座摘要

ICU中的伦理问题 Ethical issues in ICU: Withholding and withdrawing: the french experience

René ROBERT

讲座课件

Address correspondence to

René ROBERT

Service de Réanimation médicale

University Hospital of Poitiers: INSERM U927 France

E-mail: r.robert@chu-poitiers.fr

Abstract

The primary goals of intensive care medicine are to help patients survive acute severe organ failure trying to preserve their quality of lives.

However, the ICU has also become a common place to die.

In ICU in France, it has been reported that 50% of deaths occurred after withholding and/or withdrawing (WH/WD).

Along these 25 last years, thoughts about WH/WH moved from empiric and paternalistic statement to formalized, legally validated procedure.

Three situations may lead to WH/WD and should be checked every days:

Failure of optimal therapeutic strategy leading to possibility of WH/WD in the aim to not prolong agony by continuing supportive treatments;

patient with poor outcome with expected low probability of survival and /or poor quality of life suggesting that continuation or increase of intensity of treatment could be considered inordinate or unreasonable;

patient attesting directly or indirectly his refusal for new therapy or for increasing the level of organ support.

Several points should be taken into account to consider decision to WH/WD treatments in ICU patient: previous history, clinical, biological and imaging data.

It is important to check state of art / up to date to analyse prognosis and/or therapeutic option.

An expert consultant can be asked and it is important to involve other practitioners involved in the care of the patient (e.g. surgeon).

The decision should be patient-centered.

However, in most of the cases, patients are not able to make decisions for themselves because of either their illness or sedation.

When patients cannot make decisions for themselves, surrogate may help to understand the patient’s values and preferences.

The practitioner in charge of the patient has the responsibility to decide WH/WD but he has to share thoughts with medical and nurse team.

He has to inform family.

Recently the “Leonetti Law” underlined the necessity to have the point of view of an independent practitioner for WH/WH decisions.

In accordance with ethical principles, there is an important distinction between killing and allowing to die.

French “SRLF” underlines the importance to avoid the confusing terms of passive euthanasia.

The shortening of life duration may occur BUT it is not the attempted goal.

Curare, potassium or bolus sedation infusions are prohibited.

The objective is to make the patient comfortable.

WH/WD corresponds to stop cure, but it does not mean stop care.

WH/WD indicates palliative strategy.

第二届中法危重病医学研讨会暨上海重症医学论坛（2009年12月中国上海）