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Withdrawing Treatment and Deprescribing

Key Messages

  • A person’s values, goals, and preferences provide the touchstone for communication and decision-making. [1]
  • Decisions are made by clinicians, the person and family regarding withdrawing of treatment. Sometimes these decisions are made in consultation with all involved and other times clinicians make them based on clinical indicators that end-of-life is approaching. [2]
  • Sensitive discussion should precede any deprescribing as the discontinuation of a long-standing medication may cause distress to both the person and close relatives. [3]
  • When a person’s condition deteriorates in the last days to weeks of life, medications that are unnecessary for symptom relief or comfort would usually be withdrawn. [4]
  • Deprescribing unnecessary medications in a person with a palliative cancer diagnosis can benefit the person by reducing the associated cost, potential adverse effects and the burden of polypharmacy in the last months of life. [3]

Background

The following definition for deprescribing can also be applied in principle for withdrawal of treatment: Deprescribing is the systematic process of identifying and discontinuing drugs (treatments) in instances in which existing or potential harms outweigh existing or potential benefits within the context of an individual’s care goals, current level of functioning, life expectancy, values, and preferences. [5]

A shared value-based decision making model (process) for establishing goals of care and special consideration of symptom management and family support during withdrawal of life sustaining therapy is required to ensure the delivery of high quality palliative care. [1]
 

Evidence Summary

Currently, there are no guidelines for the withdrawal of treatment. Most evidence is regarding Intensive Care Unit (ICU) decision-making around withdrawal of ventilation and in people who have a critical illness involving the brain, spinal cord or nerves e.g. stroke, brain injuries and brain death. [1,6]

In the absence of guidelines, the decision to withdraw treatment includes consultation between health professionals, the individual and family. [2,4] Each situation is managed individually and once decisions are made to withdraw treatment, emotional support is an important part of the process for both the person and the family/carers. [4] Discussions of what might happen after withdrawal, including clear descriptions of withdrawal symptoms, need to be discussed. [4]

Evidence regarding deprescribing of medications is available. Two articles with strong evidence were reviewed: OncPal, an oncological palliative care deprescribing guideline [3] and STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy) [7]. The OncPal Deprescribing Guideline validation process demonstrated the incidence of potentially inappropriate medications (PIMs) in palliative cancer patients was high, 70% taking at least 1 PIM, demonstrating the potential benefits for guidelines in clinical practice. [3]

There were no articles within this search regarding the withholding of nutrition/fluids which indicate a gap in current research.
 

Quality Statement

Most of the systematic reviews were adequate with two that were high quality. In the absence of guidelines, clear and simple communication and psychosocial support are key points in all the review discussions before any decisions are made.


Page updated 24 May 2017

  • References

  • About PubMed Search

  1. Frontera JA, Curtis JR, Nelson JE, Campbell M, Gabriel M, Mosenthal AC, et al. Integrating Palliative Care Into the Care of Neurocritically Ill Patients: A Report From the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med. 2015 Sep;43(9):1964-77
  2. Clarke G, Johnston S, Corrie P, Kuhn I, Barclay S. Withdrawal of anticancer therapy in advanced disease: a systematic literature review. BMC Cancer. 2015 Nov 11;15:892.
  3. Lindsay J, Dooley M, Martin J, Fay M, Kearney A, Khatun M, et al. The development and evaluation of an oncological palliative care deprescribing guideline: the 'OncPal deprescribing guideline'. Support Care Cancer. 2015 Jan;23(1):71-8.
  4. Therapeutic Guidelines Limited. Therapeutic Guidelines: Palliative Care. Version 4. Melbourne: Therapeutic Guidelines Ltd, 2016.
  5. Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015 May;175(5):827-34.
  6. Mark NM, Rayner SG, Lee NJ, Curtis JR. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med. 2015 Sep;41(9):1572-85.
  7. Lavan AH, Gallagher P, Parsons C, O'Mahony D. STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation. Age Ageing. 2017 Jan 23.


Definition

Withholding Treatment

Withholding or withdrawal of a particular treatment or treatments, often (but not necessarily) life-prolonging treatment, from a patient or from a research subject as part of a research protocol. The concept is differentiated from REFUSAL TO TREAT, where the emphasis is on the health professional's or health facility's refusal to treat a patient or group of patients when the patient or the patient's representative requests treatment. Withholding of life-prolonging treatment is usually indexed only with EUTHANASIA, PASSIVE, unless the distinction between withholding and withdrawing treatment, or the issue of withholding palliative rather than curative treatment, is discussed. (MESH)

'Euthanasia and assisted suicide are different from withholding or withdrawing life-sustaining treatment in accordance with good medical practice by a medical practitioner. When treatment is withheld or withdrawn in these circumstances, and a patient subsequently dies, the law classifies the cause of death as the patient’s underlying condition and not the actions of others'. [1]

Decision making at the end of life can often involve very difficult and emotional decisions about whether to start or stop a treatment. For example, whether or not to start mechanical ventilation or whether to stop PEG feeding. These decisions need to consider whether something is burdensome for the patient – in other words, quality of life. (Caresearch https://www.caresearch.com.au/caresearch/tabid/1547/Default.aspx)

Search String

(((stop[ti] OR stopping[ti] OR cease[ti] OR cessation[ti] OR ceasing[ti] OR withdraw*[ti] OR discontinu*[ti] OR halt*[ti] OR withhold*[ti] OR refus*[ti] OR forego[ti] OR foregoing [ti] OR use[ti]) AND (treatment[ti] OR therapy[ti] OR hydration[ti] OR nutrition[ti] OR feeding[ti] OR ventilation[ti] OR medication*[ti])) OR "Withholding Treatment"[Mesh] OR "Deprescriptions"[Mesh] OR deprescri*[tiab] OR de prescri*[tiab])