Ethics Manual

Highlights

Patients Near     the End of Life Advance Care     Planning Problems of     Life-Sustaining     Treatments

Irreversible Loss of Consciousness

Persons who are in a persistent vegetative state are unconscious  but not brain dead. Since their condition is not progressive, patients in a persistent vegetative state are not terminally ill. They lack awareness of their surroundings and the ability to respond purposefully to them. The prognosis for these patients varies with cause. Some physicians and medical societies believe that there are no medical indications for life-prolonging treatment or access to intensive care or respirators when patients are confirmed to be in a persistent vegetative state.  

They conclude that these patients cannot experience any benefits or suffer any discomfort and that all interventions should therefore be withdrawn. However, many patients or families value life in and of itself regardless of  the neurologic state. For these reasons, goals of care should guide decisions about life-prolonging treatment for patients in a persistent vegetative state in the same manner as for other patients without decision-making capacity. 

Intravenous Fluids and Artificial Feedings

Artificial administration of nutrition and fluids is a life-prolonging treatment. As such, it is subject to the same principles for decisions as other treatments. Some stages of illness / diseases require high levels of proof before previous statements or advance directives can be accepted as firm evidence that a patient would not want these treatments in the setting of terminal illness, permanent unconsciousness, or advanced dementia. For this reason, physicians should counsel patients to establish advance care directives and complete these carefully. Clinically, there is unfounded concern that discontinuing the use of feeding tubes will cause suffering from hunger or thirst despite research findings to the contrary. Physicians should carefully address this issue with family and caregivers.