Ist ein Therapieverzicht gegen den Willen des Patienten ethisch begründbar?

Definition of the problem Decisions to limit life-prolonging treatment (DLT) precede the majority of non-sudden deaths in European countries. While existing studies focus on patient refusal of treatment, no data exists about patient consent to DLT, especially in situations where patients are not prepared to accept limitations of treatment. In a study on patient involvement in DLT we could show that one third of terminally-ill patients wish to extend their lifetime. In these patients treatment limitations are often decided without involving the patient. These data raise the question, whether doctors are allowed to limit treatment in patients who prefer “everything to be done”. Or should they rather follow the patient’s wish for intensive therapy even if they deem it futile. Arguments Neither the concept of futility nor that of patient autonomy or shared decision making are apt to guide decision making in situations where patients ask for treatment that physicians consider as futile. Using a principled approach we arrive at four criteria that should be factored in the decision and communication about limiting life-prolonging treatment: effectiveness of the intervention, the patient’s capability for autonomous decision-making based on his level of information and coping with the disease, burden of the intervention as perceived by the patient and an explicit mention of extensive treatment costs. Conclusion These criteria help to decide whether it is justifiable for the physician to limit care without consent of the patient. They also help to identify cases where continuing life-prolonging treatment on the request of the patient is justifiable even if their physicians find it inappropriate.