Stopping or not starting treatment

Sometimes a doctor decides not to administer antibiotics to a seriously ill patient who also contracts pneumonia. Normally, a doctor would treat pneumonia, but due to the patient's serious situation, he decides not to. The patient will probably soon die, partly as a result of this decision. We call this not starting treatment.

In other cases, a doctor may decide to stop treatment. Consider for instance a patient who is in a long-term coma and who is being fed by means of a feeding tube, whereby the doctor decides to remove the feeding tube. Because the patient no longer receives food and (other) fluids, death can be expected within a few days.

Sometimes not starting or stopping treatment can be combined under one heading, namely abstinence.

The key question behind all these decisions is: is it responsible to not start treatment or to stop treatment for a patient? And: what is the underlying motive?

Why not start or stop treatment?

Clearly, a doctor will not lightly decide not to start or to stop treatment. There is always a reason for this. That reason is extremely important. In general, two reasons can be distinguished:

• the doctor considers the treatment to be pointless, or
• the doctor thinks the life is pointless, due to the serious illness or serious handicap.

In practice, this distinction is blurred, because a judgement about whether a treatment makes sense is always connected with the general situation of the patient. For instance, a high-dosage chemotherapy with a young cancer patient may make sense, while the same treatment for an old patient would be too much of a burden, and so be pointless.

Yet it is important to distinguish between these two reasons. Because we may not pass judgement on the meaning of life, however ill the patient is. If we confess that life is given by God, then it is not for us to give a value judgement (really: to pass sentence). But we should ask ourselves whether the treatment makes sense. After all, not every treatment makes sense. Sometimes a treatment has more disadvantages (side-effects) than advantages. This does not serve the patient's welfare.

Not starting treatment

In general, a doctor will decide not to start treatment, if the advantages of the treatment no longer weigh up against the disadvantages. For instance, a seriously ill patient is no longer given antibiotics, because the drug would have no effect. If a patient is dying, a doctor will not usually artificially administer food (drip) or fluids (infusion), although the patient no longer drinks anything, because this treatment would be too taxing. Such a treatment would no longer be compassionate, neither does it fit into the (natural) dying process in which the requirement for fluids is strongly reduced and the demand for food disappears altogether.

It is totally different if a doctor does not start treatment, because he considers the patient's life to have no meaning. Consider for instance a surgeon who refuses to operate a child because the child has Down's syndrome. Then the doctor is really passing judgement on the meaning of life, rather than about the point of the treatment. It is not for us to pass this judgement.

Stopping treatment

The same applies to stopping treatment. Usually a doctor will stop treatment, if the disadvantages will apparently be greater than the advantages. If for instance a drip feed can no longer be tolerated, then this treatment must be reduced and stopped. If the dialysis treatment becomes ever more taxing for a weak patient, the doctor will eventually have to stop this treatment.

Unfortunately, when stopping a treatment, the meaning of life is soon taken into account. To avoid this, it is important to carefully weigh the advantages and disadvantages of the treatment. So the doctor will have to provide a clear explanation. It is sometimes advisable to give the family a period of consideration (because usually the patient himself can no longer decide), before agreeing with the doctor. During this time for consideration, the family can obtain advice from for instance a consultation desk of the NPV (Dutch Patients Association). By the way, this also applies for the health carer, certainly if there are any doubts about the motive for the policy change. Good communication with the doctor is essential in this respect.