Some broad understanding of the key legal cases involving the limitation of life-sustaining treatment and the provision of palliative care will help clinicians improve their practice in this important aspect of ICU care.7,10,11 The first and most important case was the Quinlan case decided by the Supreme Court of New Jersey in 1976. Karen Quinlan was a 22-year-old woman in a persistent vegetative state, who was receiving mechanical ventilation in a New Jersey hospital’s ICU after presenting with a drug overdose and suffering a cardiac arrest. Her father felt that his daughter would not want to remain alive in such a state and he wanted to be named her guardian so that he could order the removal of the mechanical ventilator. The hospital and the physicians involved in her care refused, arguing that removing the ventilator would be euthanasia. The Supreme Court of New Jersey reasoned that Quinlan would have refused further treatment and that she had the right to refuse any life-sustaining treatment. Since the patient was incompetent to exercise that right, the court further ruled that the only practical way for that right to be maintained would be for the family to render their best judgment as to whether she would exercise it in these circumstances.
By ruling in this way, the Quinlan court rejected any distinction between withholding and withdrawing life-sustaining treatment and acknowledged the importance of surrogate decision-making in end-of-life care. The Quinlan opinion also went further by acknowledging the limitations of the law in resolving future conflicts in this arena and encouraged the use of hospital ethics consultation as a more appropriate mechanism for resolving these conflicts in the future. By 1991, this recommendation for an ethics consultation was operationalized through the Joint Commission on Accreditation of Healthcare Organization’s (JCAHO’s) requirement that (1) hospitals follow ethical behavior in its care, treatment, services, and business practices, and (2) they establish and maintain structures to support patient rights; these include patients’ right to refuse care and patients’ wishes relating to end-of-life decisions.8
In the years following Quinlan, multiple court cases in the United States firmly established the right of the competent patient to refuse any medical treatment. However, there was considerable variation in how different state courts felt it best to exercise this right of refusal for life-sustaining treatments in patients without decisional capacity. The issue of how different U.S. states dealt with the patient’s right to refuse life-sustaining treatment first came to the U.S. Supreme Court through the Cruzan case.
Nancy Cruzan was a young woman hospitalized in Missouri in a persistent vegetative state after an automobile accident, who required artificial nutrition and hydration to stay alive. The family requested that the feedings be stopped because they felt that Nancy would not have wanted to continue treatment in her health state. The Missouri State Supreme Court ruled in 1988 that since the state had a legitimate interest in preserving life, life-sustaining treatments could only be removed by surrogate decision-makers if there was “clear and convincing evidence” confirming that the particular patient would have rejected such treatment.
The U.S. Supreme Court, in Cruzan v. Missouri Department of Public Health (1990), recognized the constitutional right of the competent person to refuse life-sustaining treatments of all types, including life-saving hydration and nutrition. At the same time, the Supreme Court affirmed the Missouri State Supreme Court by ruling that the United States Constitution did not prohibit a state from having a high evidentiary standard (clear and convincing standard lies somewhere between the civil standard of a preponderance of the evidence and the criminal standard of beyond a reasonable doubt) for surrogate decision-making regarding life-sustaining treatments.
In a concurring opinion, Sandra Day O’Connor suggested a larger role for advanced directives as a potential mechanism to safeguard the patient’s interest in directing his or her medical care in the event that they become incompetent. Influenced by Sandra Day O’Connor’s opinion, Senators Danforth (of Missouri) and Moynihan (of New York) enacted a law entitled the Patient Self Determination Act (PSDA), which became law in 1991 and required health care institutions to provide adult patients with information about advance directives upon admission.
In Washington v Glucksberg and Quill v. Vacco (1997), the question presented to the U.S. Supreme Court was whether prohibitions against physician-assisted suicide offended the United States Constitution. The Supreme Court concluded that terminally ill patients do not have the right to physician-assistance in suicide under the United States Constitution.
However, the Supreme Court did rule in favor of a patient’s constitutional right to obtain relief from suffering, including terminal sedation. Justice O’Connor in Glucksberg inferred a constitutional right to “obtain relief from suffering” and Chief Justice Rehnquist in the majority opinion in Vacco v. Quill invoked the doctrine of double effect in his affirmation of the practice by clinicians of relieving pain with medicines, even if those medicines come with the possibility of hastening death.11 The doctrine of double effect is a Catholic moral argument that tries to make distinctions between intended effects and merely foreseen effects by permitting an act to be done that may have two foreseen effects, one good (such as relieving pain) and another harmful (such as death), when the intent is to produce the good effect and the harmful effect is foreseen but not intended. This doctrine, although philosophically imperfect, provides justification for the use of opioids and sedatives to maintain the comfort of the patient, even if the clinician sees the potential that the drugs may shorten the time to death.
In general, when asked to resolve disputes between families who request potentially inappropriate treatment and physicians who oppose it, courts in the United States have been reluctant to withdraw treatment that would lead to death over the objection of the family.11 In the case of Helga Wanglie, an 86-year-old woman was in a persistent vegetative state after a series of medical complications over the course of several months, and was chronically dependent on the mechanical ventilator. The hospital wanted to remove the mechanical ventilator citing that the respirator was nonbeneficial. The patient’s family objected on moral and religious grounds. The hospital then went to the Court asking for an independent conservator to make medical decisions for the patient instead of the family, but the court rejected the hospital’s request. On the other hand, courts have also been reluctant to punish clinicians who act carefully and within professional standard to limit life-sustaining treatments. In Gilgunn, a Massachusetts jury imposed no liability on the hospital or the clinicians after they removed the ventilator from a terminally ill patient over the objection of her family.