Withholding Treatment

Situation

C.J., a 26-yr-old patient in a permanent vegetative state, is diagnosed

with her 15th bladder infection. As her home care nurse, you must

determine whether to seek antibiotics for this infection. The family

members have expressed a concern that no heroic measures be used

to extend the life of their daughter and sister. However, they have

been unwilling to stop providing enteral nutrition through a

gastrostomy tube. Should antibiotics be withheld?

Ethical/Legal Points for Consideration

• Patients in a persistent vegetative state do not recover.

• The main legal issue here is who has the legal right to refuse or

consent to treatment for this incapacitated patient. You need to

know if a guardian has been appointed by the court or if her

parents retain a form of guardianship to make health care

decisions for her.

• You need to know when the vegetative state began; that is, did

the patient ever have the right to consent having reached the age

of majority as a competent adult or did the vegetative state begin

while she was a minor? If the patient did become a competent

adult before the vegetative state, did she ever express any

preference for quality-of-life and end-of-life decision making?

• The courts have widespread legal precedents for accepting the

decision of the patient’s guardian or parents or the patient’s

clearly expressed preferences for quality-of-life decision making.

• Life-sustaining treatment is any treatment that serves to prolong

life without reversing the underlying medical condition. Lifesustaining treatment may include, but is not limited to,

mechanical ventilation, renal dialysis, chemotherapy, antibiotics,

and artificial nutrition and hydration.

• There is no ethical distinction between withdrawing and

withholding life-sustaining treatment. If there is not adequate

evidence of the incompetent patient’s preferences and values, the

decision should be based on the best interests of the patient (i.e.,

what outcome will most likely promote the patient’s well-being).

Discussion Questions

1. How would you approach C.J.’s family?

2. What are your feelings about providing nutrition, hydration,

and treatments that will prolong life in a patient for whom

there is no hope of recovery?

3. What options are available to the family for the care of their

daughter once a decision is made about withholding

antibiotics?