This was a statement issued in 2000 to the Hong Kong Medical Council in response to an article in the South China Morning Post regarding withholding or withdrawal of life support in the Intensive Care Unit. For your reference.
To: The Hong Kong Medical Council
Re. Withholding or withdrawal of life support in the Intensive Care Unit
As a group of concerned medical practitioners, we welcome the attention the Medical Council paid to the important issue of the dying process of patients in Hong Kong. However, we would like to express some concern regarding the press release (South China Morning Post, 14 January 2000) from the Medical Ethics Committee regarding the ‘sanctioning of passive euthanasia’. We would like to respectfully bring to the Council’s attention our opinion regarding four important points made in the article.
Firstly, The HKSCCM would like to stress the distinction between euthanasia (passive or otherwise) and withholding and withdrawal of therapy. Euthanasia is defined as ‘direct intentional killing of a person as part of the medical care offered’. Our understanding is that euthanasia is illegal in most parts of the world, including Hong Kong. Intensive care professionals in Hong Kong do not practice euthanasia. The practice of withholding and withdrawing life support is, however, common. The increasing incidence of withholding and withdrawing therapy is related to rapid advancement of technology which has made it possible to continue life support long after meaningful recovery is not possible. It is to avoid the unfortunate consequences of continuous, hopeless life support that withholding and withdrawing life support has become necessary. Withholding or withdrawing life support is not done with the intention of killing the patient. The intention of withholding or withdrawing life support is to help the dying achieve a peaceful and dignified death, so that the process of suffering and death is not unnecessarily prolonged. This is appropriate and accepted practice in most parts of the world, including Great Britain, Continental Europe, Australasia and the United States. There is plentiful evidence from published medical literature that withholding or withdrawing therapy is common practice around the world, and that a high percentage of deaths in the ICU (70%-90% in some ICUs) are now preceded by a decision to withhold or withdraw therapy.
In principle we support the statement that the decision to limit therapy “can be made only if the patient’s family, doctors and hospital administrators agree”. However, at present, in most places around the world, including Hong Kong, the practice of withholding or withdrawing therapy does not routinely involve hospital administrators and/or hospital ethics committees. The decision to recommend withholding or withdrawing therapy is ultimately the responsibility of the critical care physicians and the primary physicians, although this can be done in consultation with the ethics committee. Often wide consensus is reached before a decision is made, and patient’s families also often readily accept their physician’s recommendations to limit life-sustaining treatment. A refusal to allow withdrawal life support is not common, and often temporary. However, discussions of withholding and withdrawal of life support can be emotionally difficult and can present special challenges in communication. In this regard establishing a panel of experienced administrators, community representatives and doctors to facilitate the process of ethical decision making can be beneficial. The resource implications involved in this sort of ideal undertaking are, however, enormous and need to be considered when practice recommendations are made. The article stated that “we expect that there will be several such applications for passive euthanasia each year”. However, based on current data, the frequency of withholding or withdrawing therapy in the intensive care unit is much higher than this. We predict that the number will be at least several a week in a big intensive care unit.
Thirdly, we have some concern regarding the statement that “individual hospital ethics committees must also prove that the patient has no chance of recovery before doctors could unplug a life-support system”. There are currently no prognostic scoring systems that can predict death or survival with 100% accuracy and all definitions of hopelessness and futility have proved unsatisfactory. Surveys and studies have consistently shown that physicians do make recommendations to withhold or withdraw therapy while there was still a theoretical possibility of survival. Some of the well accepted reasons for recommendations to withhold or to withdraw therapy include the following: low probability of survival, co-morbid illnesses making death likely, poor quality of life for the patient, patient suffering disproportionate to expected medical benefits and patient’s advance directives. Therefore the limitations of current medical practice in intensive care units make compliance with the above statement impossible.
Fourthly, the article stated that “saving resources was one consideration taken into account” in decisions to remove life support. We agree that one step to fair allocation of scarce resources is for physicians, backed by hospital policy and appropriate ethics consultation, to withhold or withdraw therapy in critically ill patients who will not benefit from continuing ICU care. However, it is not the practice of medical professionals in intensive care units to use medical costs as the sole justification for withholding or withdrawal of life support. In no instance should life support be withheld or withdrawn in order to provide space for another patient in an overcrowded intensive care unit.
As intensive care physicians, we are constantly make important decisions about provision and withdrawal of life support. We fully support the Medical Council in developing guidelines on issues such as euthanasia and the withholding and withdrawal of therapy. We believe that the Council guidelines should reflect the values of the society that we all serve. As a group of concerned medical professionals, we trust that we have contributed to the forum on these issues by making our position known to you. Should you require any clarification or further information from our society we would offer our full cooperation.
Hong Kong Society of Critical Care Medicine