Pulling supplemental oxygen creates struggle

Guide addresses how to respond to patient request

The right of competent, informed patients to reject lifesaving therapies has been affirmed by courts at every level, but a group of ethicists at the University of Pennsylvania wondered whether the line is as clear when it comes to supplemental oxygen.

Scott Halpern, MD, PhD, senior fellow with the Center for Bioethics at the University of Pennsylvania Health System and a fellow in the division of pulmonary, allergy, and critical care, has co-authored a guide for providers whose patients request removal of oxygen.

"Informed patients with decision-making capacity have well-established rights to forgo any and all forms of life-sustaining therapy," says Halpern. "However, there is no clear definition of what constitutes a life-sustaining therapy."

While life-sustaining therapy is often thought of as invasive therapies, such as mechanical ventilation, kidney dialysis, or tube feeding, non-invasive high-flow oxygen is also life-sustaining in patients with advanced lung, heart, or cancer-related diseases, he points out.

"Many of these patients would lose consciousness and die within hours or even minutes if their supplemental oxygen was withdrawn," Halpern says.

Halpern and co-author John Hansen-Flaschen, MD address concerns physicians who have not undergone specific training in critical care may have about withdrawing oxygen, including how to balance the burdens and benefits of supplemental oxygen; whether withdrawing oxygen might appear neglectful; how to determine whether patients retain decision-making capacity; when it is acceptable to use sedation in lieu of oxygen; and concerns about patients' motivations for discontinuing oxygen.

Experience leads to four-step approach

Both Halpern and Hansen-Flaschen, who serves as chief of Penn's division of pulmonary, allergy, and critical care medicine, arrived at the guidelines, published in September in the Journal of the American Medical Association,1 through experience.

Both Halpern and Hansen-Flaschen recount experiences where they received requests from patients to stop their flow of supplemental oxygen, resulting in death. Halpern was first faced with the request to withdraw oxygen as a first-year medical resident, when an awake and alert patient suffering from advanced lung disease and cancer asked to end the oxygen supplement. One morning, the patient said he'd "had enough" and tugged on his mask, but was too weak to remove it and asked for Halpern's help. Halpern recalls that he debated the request with the attending physician, who was concerned that the patient would experience air hunger and fear after oxygen was removed, necessitating high doses of sedating drugs, and worried this might constitute a form of euthanasia.

Hansen-Flaschen received a similar request from a homebound outpatient who suffered from advanced lung disease. The patient could no longer get out of bed and his quality of life had seriously deteriorated, and he asked to stop his oxygen and for Hansen-Flaschen to help him avoid a sense of suffocation afterwards.

"I had to ask myself, is this participating in a patient's death or is it simply respecting a patient's request?" Hansen-Flaschen explains. "Plus, there's no way to predict an individual's response to removing supplemental oxygen and how much they will suffer."

Advances in medicine mean that many more patients with end-stage diseases are living longer, and technology permits high-flow supplemental oxygen to be used both in the hospital and at home, often providing a limited quality of life.

"So this is yet another ethical dilemma in medicine born of technological advancements," observes Halpern.

Halpern and Hansen-Flaschen offer a four-step approach to help physicians meet requests to end supplemental oxygen and to overcome the concerns such requests create:

  • Physicians should assure themselves and other health care professionals involved in the patient's care, as well as the patient's family members and close friends, that supplemental oxygen is a form of life-sustaining medical treatment. As such, requests to discontinue oxygen should be honored with the same judiciousness as requests to withdraw other forms of life support;
  • Physicians should ensure that patients requesting the terminal withdrawal of oxygen are free from undue influences, including family member's wishes, economic considerations, or treatable depression;
  • Physicians should ensure that the patient has the capacity to make medical decisions by documenting that patients show consistency, understanding, and rationality in making such requests;
  • Physicians should ensure that patients and their family members understand the difficulty of predicting patients' experiences after oxygen withdrawal.

Reference

1. Halpern SD, Hansen-Flaschen J. Terminal withdrawal of life-sustaining supplemental oxygen. JAMA 2006; 296:1,397-1,400.

Sources

For more information, contact:

  • Scott D. Halpern, MD, PhD, Senior Fellow, Center for Bioethics, University of Pennsylvania Health System. 711 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104. E-mail: scott.halpern@uphs.upenn.edu.