Paediatrics: Withholding or withdrawing treatment in children

Withholding or withdrawing treatment in children

There are medical situations where the treatments used to try to keep a child alive will neither restore them to health, nor provide them any other meaningful benefit. In these circumstances treatments such as mechanical ventilation, heart pumps, etc., may no longer be in the child’s best inter-ests.

Ethical framework

·  Duty of care and the partnership of care: our duty as part of the health care team is to comfort and to cherish our patient, the child, and to prevent them experiencing pain and suffering. We undertake this in partnership with the child’s parents or carers.

·  Legal duty: all health care professionals are bound to fulfill their duty within the framework of the law. Any practice or treatment given with the intention of causing death is unlawful.

·  Respect for children’s rights: our treatments for children should have ‘their best interests’ as a p consideration.

Double effect

It is recognized in English and Scottish law that, e.g. increasing doses of analgesia, necessary for the control of pain or distress, may shorten life. We use opiates for the benefit of the child during life and we do not use them to cause or hasten death, but this may be a consequence—the dou-ble effect. The principle has four frequently cited conditions:

·  The action must be either morally good or neutral.

·  The bad effect must not be the means by which the doctor achieves the good.

·  The intention of the doctor must be the good effect.

·  The good effect must be equivalent or greater than the bad.

Euthanasia

Withholding or withdrawal of treatments, such as ventilation often does not lead to death. It should be clear that active measures to shorten life are not appropriate or legal and that palliative care is to be continued.

Process of decision-making

Making a decision about withholding or withdrawing life-sustaining treat-ment requires time. It is advisable that the whole team is involved, and enough information and evidence about the child’s condition is availa-ble. The decision to withhold or withdraw life-sustaining therapy should always go hand in hand with planning palliative care needs.

·  Process: while decisions are being made the child’s life should be safeguarded in the best way possible.

·  Responsibility: the clinical team carries the corporate moral responsibility for decision-making. The senior member of the team is the consultant in charge of the child’s care and should lead the decision-making

process: s/he bears the final responsibility for the chosen course of action.

·Family and parents: the final decision about withdrawal of treatment is made with the consent of the parents. Good communication is essential, as is building a relationship based on trust.

·Second opinions: it is good practice to consider this option. Other consultants  within the team may have advice. However, additional input from experts in another hospital may be required. This is particularly useful in unusual circumstances where there is uncertainty about prognosis and the child’s likely future impairments.

·Legal input: with time, effective communication, and support, the decision-making process in most cases can be brought to a resolution. There are instances where hospital legal advisers and court involvement are required, especially where there is disagreement between parents or parents and the medical team involved about the right way to proceed.

Professional framework

The Ethics Advisory Committee of the Royal College of Paediatrics and Child Health (RCPCH) identified five situations where it may be ethical and legal to consider withholding or withdrawal of life-sustaining treatment. These are summarized in the Box 31.3.

Where there is disagreement, or where there is uncertainty over the degree of future impairment, the RCPCH advises that the child’s life should always be safeguarded until these issues are resolved.

Box 31.3 Ethics Advisory Committee of the RCPCH recommendations

See ‘Witholding or withdrawing treatment in children’, May 2004, M www. bapm.org/publications/document/guidelines/Withholding&withdrawing_ treatment.pdf

·  Brain death: mechanical ventilation in such circumstances, where specific criteria are met, is futile and the withdrawal of ICU treatment is appropriate

·  Permanent vegetative state: this state, which has specific diagnostic criteria, follows brain insults such as trauma and hypoxia. It may be appropriate to withdraw or withhold life-sustaining treatment

·  No chance: the child has such severe disease that life-sustaining treatment simply delays death without significant alleviation of suffering. Treatment to sustain life is inappropriate

·  No purpose: the child may be able to survive with treatment, but the degree of physical or mental impairment will be so great that it is unreasonable to expect them to bear it

·  Unbearable: the child or family feel that, in the face of progressive and irreversible illness, further treatment is more than can be borne. They wish to have a particular treatment withdrawn or to refuse further treatment irrespective of the medical opinion that it may be of some benefit