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February 23, 2000

Withdrawing Very Low–Burden Interventions in Chronically Ill Patients

Author Affiliations

Author Affiliations: Huffington Center on Aging (Drs Rhymes, McCullough, Luchi, Teasdale, and Ms Wilson) and Center for Medical Ethics and Health Policy (Dr McCullough), Baylor College of Medicine, Houston, Tex.


Controversies Section Editor: Phil B. Fontanarosa, MD, Deputy Editor.

JAMA. 2000;283(8):1061-1063. doi:10.1001/jama.283.8.1061

Discussions of withdrawing or withholding treatment from patients have focused, for the most part, on critical care management of gravely ill patients or those with advanced or end-stage disease. In this article, we address the distinctive ethical issues that arise when the physician considers withdrawing low-burden clinical management from chronically—but not critically—ill patients.

Reverend G is an 85-year-old white man with severe dementia. Except for dementia, he is in fairly good physical health. He had a pacemaker implanted several years previously. He has marked behavioral problems, including combativeness and physical aggression, and no longer recognizes his family members. He now resides in a nursing home in a locked dementia unit. Multiple trials of neuroleptics (typical and atypical), trazodone, and sedatives have failed to control his hallucinations and aggressive behavior and/or caused serious adverse effects (gait instability, falls, swallowing problems, and fecal incontinence). When the patient is not taking the medications, his behavior is abusive, aggressive, and assaultive. Reverend G had executed a living will before his dementia became severe. However, he said he would not want to commit suicide. His wife and children agree that Reverend G is without quality to his life. His wife, with agreement from their children, has asked that the patient be given treatment to keep him comfortable and has further asked that his pacemaker be turned off, on the assumption that the pacemaker may prevent an otherwise natural death, which they view as what the patient would want in his current circumstances if he were able to make decisions.

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