End-of-Life Issues

Cessation of Treatment

Under review

Nancy B. is 23 years old when admitted to hospital. Two years later, she remains totally dependant on the respirator due to Guillain-Barré syndrome. She asks to be taken off the respirator.
What do you do?

The example of Nancy B. is a case that was submitted to the courts in Québec City in 1992. Recourse to the courts was precipitated by the ambiguity experienced on a clinical level. Indeed, the  Criminal Code,  of federal jurisdiction, continues to convey ambiguities and lack of clarity on the legal implications of the cessation of treatment This recourse to the courts confirmed that the physician who disconnects a respirator in response to the free and informed request of a patient does not commit an unreasonable act or an act of criminal negligence. This act cannot be considered to be homicide. In reading the judgment, it is clear that this is a case of refusal of treatment and that respect for the autonomy and  free and informed consent of the patient takes precedence in these cases. In fact, the cessation of treatment poses a problem when the person cannot interrupt the treatment herself and the interruption necessitates the participation of a third party. In this case, the physician had to agree to terminate the treatment at Nancy B.’s request. The situation is different when an autonomous patient refuses to continue treatment; in this case, the patient simply stops coming for treatment, stops taking her medication or signs a refusal of treatment.

Usually, the question of cessation of treatment arises when the patient’s physical autonomy is compromised. This question gives rise to another, which touches on proportionate treatment as opposed to disproportionate treatment. These notions help us better evaluate the reasonable options, given the diagnosis on the one hand, and the intensity of the treatment sought after on the other. Care is said to be proportionate or disproportionate according to the desired goal: does one envisage a cure, maintenance or relief for the patient? If a cure or remission is impossible, maintenance and supportive care may be the only relevant or desirable option.

It is important that the maintenance and supportive care not conflict with the obligation to provide relief, from which no physician is exempt. On this matter, section 58 of the Code of Ethics of Physicians stipulates the following:

A physician must, when the death of a patient appears to him to be inevitable, act so that the death occurs with dignity. He must also ensure that the patient obtains the appropriate support and relief.”

Analgesia in order to provide comfort, for example, is an approach widely used in palliative care.

The story of Nancy B. brought to light the conflict between the principle of selfdetermination and the sacredness of life, which, for many, can still exist. In fact, from this legal debate emerged the questions of assisted suicide and euthanasia.