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  • Print publication year: 2010
  • Online publication date: March 2012

17 - Withholding and withdrawing life support in the intensive care unit

from 2 - End-of-life issues


The principle of respect for patient autonomy supports a pregnant woman's rights to refuse recommended medical treatments, even if such refusal may be detrimental to her or to her fetus. The incidence of cesarean delivery without medical or obstetrical indications is increasing in the US, one component of which is cesarean deliveries at maternal request (CDMR). Principles of beneficence and nonmaleficence are particularly challenging with CDMR, since they must balance benefits and harms for both mother and baby in a situation where there is a lack of reliable authoritative data, physicians' own personal views may vary widely, and there is heated political as well as medical debate. The anesthesiologist probably would not have been directly involved in the patient's and obstetrician's decisions regarding mode of delivery. When patients request unnecessary interventions, additional ethical considerations include issues of distributive justice.


1* Siegel, M.D. (2009). End-of-life decision making in the ICU. Clin Chest Med, 1, 181–94.
2* Way, J., Back, A.L., and Curtis, J.R. (2002). Withdrawing life support and resolution of conflict with families. BMJ, 325, 1342–5.
3* Guidelines for intensive care unit admission, discharge, and triage. (1999). Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med, 27(3), 633–8.
4* Burns, J.P. and Truog, R.D. (2007). Futility: a concept in evolution. Chest, 132(6), 1987–93.
5* Truog, R.D., Campbell, M.L., Curtis, J.R., Haas, al. (2008). Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. [erratum appears in Crit Care Med. 2008 36(5), 1699]. Crit Care Med, 36(3), 953–63.
6* Berger, J.T., DeRenzo, E.G., and Schwartz, J. (2008). Surrogate decision making: reconciling ethical theory and clinical practice. Ann Intern Med, 149(1), 48–53.
7* Pochard, F., Azoulay, E., Chevret, S., et al. (2001). Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity. Crit Care Med, 29(10), 1893–7.
8* Fried, T.R., Bradley, E.H., Towle, V.R., and Allore, H. (2002). Understanding the treatment preferences of seriously ill patients.[see comment]. N Engl J Med, 346(14), 1061–6.
9* Heyland, D.K., Cook, D.J., Rocker, G.M., et al. (2003). Decision-making in the ICU: perspectives of the substitute decision-maker. Intensive Care Med, 29(1), 75–82.
10* Heyland, D.K., Frank, C., Groll, D., et al. (2006). Understanding cardiopulmonary resuscitation decision making: perspectives of seriously Ill hospitalized patients and family members. Chest, 130(2), 419–28.
11* Curtis, J.R. and White, D.B. (2008). Practical Guidance for Evidence-Based ICU Family Conferences. Chest, 134(4), 835–43.
12* Kagawa-Singer, M. and Blackhall, L.J. (2001). Negotiating cross-cultural issues at the end of life: “you got to go where he lives.”JAMA, 286(23), 2993–3001.

Further reading

Beauchamp, T.L. and Childress, J.F. (2009). Principles of Biomedical Ethics. 6th edn. New York: Oxford University Press.
Medical futility in end-of-life care (1999). Report of the council on ethical and judicial affairs. JAMA, 281, 937–41.
Ratnapalan, M., Cooper, A.B., Scales, D.C., and Pinto, R. (2010). Documentation of best interest by intensivists: a retrospective study in an Ontario critical care unit. BMC Med Ethics, 11, 1.