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To the Editors:
Many patients in ICUs reach a point when it can be reasonably inferred that meaningful survival is not likely and continued medical interventions are deemed futile.1 At this point, the physician makes a decision in concert with an interdisciplinary team to withdraw care. The phrase withdrawing care typically originates from the medical profession, but its perceived meaning is rarely challenged by nursing. Use of phrases such as withdrawing care is inappropriate. The discipline and profession of nursing should uphold the social contract of patient advocacy by critiquing this phrase and avoiding its use when discussing potential end-of-life planning.
The role of the nurse as an advocate for patients is not a new concept. From the beginning of our education we learn that advocacy, grounded in a framework of caring, is at the very core of our existence in the health-care system. Further, in 1980, the American Nurses Association’s Social Policy Statement2 directly indicated "Nurses are committed to respecting human beings because of a profound regard for humanity." The discipline and profession of nursing claims that caring is fundamental to its practice.3 Although nurses identify themselves as patient advocates charged with upholding dignity and respect, nurses implicitly surrender to the medical phrase withdrawing care.
The phrase withdrawing care has many perceived negative undertones. Consider the word withdrawal. Society uses this word in context to describe the process of taking away. Some synonyms for withdrawal include departure and abandonment, yet these words are not directly related to or congruent with the nursing process of assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Imagine for a moment nurses and doctors discussing a case in the intensive care unit and without their knowledge, the patient’s family overhears the phrase withdrawing care. How would the family perceive this phrase without absolute clarity? Watson4 describes care as the basis for human healing. If caring is at the fundamental core of nursing, how can a nurse then agree to participate in an intervention described as taking away, departing, or abandoning human healing or the human condition?
I submit that we do not withdraw care from a patient for whom medical interventions become futile. Consider an image suggesting nurses and doctors taking the patient and dropping him off at the curbside or placing her in a garbage dumpster. Clearly these actions would never happen. Therefore, we should agree that we are in fact not withdrawing care, but rather changing the patient’s treatment plan.
The death and dying process is a precious time that we as nurses are privileged to witness and take part in. Although the patient may no longer receive active life-sustaining interventions such as mechanical ventilation, nursing in its caring tradition continues to ensure that the patient is comfortable, that family members are supported, and that necessary actions are taken to promote a good death. These actions are not reflective of taking away, departing, or abandoning human care, but represent respect while exhibiting a profound regard for humanity. Thus, nursing acts on a change in treatment plan instead of participating in the withdrawal of care from a patient.
Nurses as patients’ advocates should be alarmed when they hear the phrase withdrawing care. This phrase tears at the very fabric of nursing and should be eliminated from everyday nursing vernacular. I call on the discipline and profession of nursing to unite on this issue and uphold patient advocacy by challenging those who use the phrase withdrawing care. Nurses are empowered to defend patients’ dignity and should promote appropriate terminology associated with patients’ care even at the end of life.
Denver, Colo
REFERENCES
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