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Families and the Decision to Withhold or Withdraw Life-sustaining Therapy from the Critically Ill: Are Pressure Tactics Ever Justified?

It was a pleasure to read the critical care perspective by Drs. Luce and White on the topic of pressure to withhold or withdraw life-sustaining therapy from critically ill patients in the United States (1). Though we agreed with some portions of the perspective, we have objections to other portions.

It seemed as if the authors of the perspective supported the idea of using pressure tactics to achieve desired results in the ICU (intentionally or unintentionally). It was mentioned in the very first paragraph of this perspective that "exerting pressure on the families of critically ill patients ... may be appropriate in some circumstances," and there was a follow-up on page 1,106 of the article with a subheading, "When Is the Pressure Appropriate?" We strongly believe that using pressure tactics on the families of critically ill patients in the ICU is neither allowed legally (2) nor ethically (3). Moreover, pressure on the families may be counterproductive and is dangerous to the patient–physician relationship (4). While we are aiming for an equal partnership with patients and patients' families in the ICU (5), advising that exerting pressure on the families in the ICU for decision making "may be appropriate sometimes" seems like an overuse of the ethical principle of paternalism.

If we want to achieve proper results in the ICU, we must strive to improve the leadership skills of the ICU doctors and nurses (6), who must gain the trust of the patients and patients' families sooner or later in the course of care. We must always strive to empathize with the patients' families rather than using "pressure" on them. It seemed paradoxical that, while advising clinicians to use "due process" in resolving conflicts, the authors of the critical care perspective (1) tried to justify occasions when pressure is appropriate in the ICU.

Hari Dandapantula, Vishnuvardhan Reddy and J. Richard Spears

Wayne State University
Detroit, Michigan

REFERENCES

1. Luce JM, White DB. The pressure to withhold or withdraw life-sustaining therapy from critically ill patients in the United States. Am J Respir Crit Care Med 2007;175:1104–1108.[Abstract/Free Full Text]
2. Luce JM, Alpers A. End-of-life care: what do the American courts say? Crit Care Med 2001;29:N40–N45.[CrossRef][Medline]
3. Meisel A, Snyder L, Quill T. Seven legal barriers to end-of-life care: myths, realities, and grains of truth. JAMA 2000;284:2495–2501.[Abstract/Free Full Text]
4. Pellegrino ED. Patient and physician autonomy: conflicting rights and obligations in the physician-patient relationship. J Contemp Health Law Policy 1994;10:47–68.[Medline]
5. Wu AW, Sexton JB, Pronovost PJ. Partnership with patients: a prescription for ICU safety. Chest 2006;130:1291–1293.[Medline]
6. Saultz JW. Viewpoint: are we serious about teaching professionalism in medicine? Acad Med 2007;82:574–577.[CrossRef][Medline]

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