Doctorin' with Double Effect Part II: The Devil is in the Details

In a prior post, Doctorin' with Double Effect, (a double entendre with Doctrine of Double Effect) I attempted to tease out ethical issues related to the withdrawal of life support and specifically the provision of oxygen in dying patients.  The simplest case is that of a moribund patient who is completely dependent upon life support measures such as mechanical ventilation and vasopressors.  In such a patient, withdrawal of these measures often allows a quick death to ensue.  Provision of oxygen in such a patient will not avert death, but will prolong it, so I think that while oxygen is often reflexly applied to such patients, I can say with some confidence that it should not be.  While it is mostly benign, it generally does not provide comfort and it prolongs the dying process so it is on the net futile or harmful.  I struggle to reconcile my strong pragmatic intuition about this with ethical principles such as the DDE, although I think it is consistent with the notion that I can take away something that restores a natural state to abrogate its associated discomforts or in deference to patient autonomy and a wish to have a "natural death."

But there is a very large grey area.  What about patients in whom death is not imminent?  Consider a patient who has been on the ventilator for a week with dementia and aspiration pneumonia, and who has developed weakness.  He is alert, but not oriented.  When he is extubated, it is expected that he will develop retained secretions, atelectasis, and over several days, obtundation and oxygenation and ventilation failure.  But over several days.  Should oxygen be administered in the hope that he will rally?  Does its deprivation deprive him of a chance of survival that is disproportionate to the removal of the endotracheal tube and the mechanical ventilator in terms of net costs and benefits?

Or, consider the patient who is demented and is admitted with pneumonia from aspiration and who is DNR/DNI and is given supplemental oxygen.  Does escalation of oxygen therapy to a non-rebreather mask from nasal cannula fly in the face of his DNR order?  Does the administration of peripheral vasopressors for hypotension have the same result?  Does DNR/DNI mean Do Not Respond/Do Not Intervene?

Doctorin' with Double Effect: The Ethics of Withdrawal of Life Support and Oxygen in Dying Patients

There has been a lot of discussion about the ethical nuances of withdrawal of life support and provision of medications that relieve suffering but accelerate death, but precious little about an important aspect of end of life care that comes up all the time - what are our obligations regarding provision of oxygen to dying patients?

The withdrawal of life support is an activity (a commission) that is ethically protected because patients' autonomy and right to refuse treatments overrides the harm (death) that comes about when physicians act to withdraw life support.  This in itself is interesting because most states prohibit euthanasia (or the provision of prescriptions that enable patients to take their own lives), which is in essence a commission (as opposed to an omission) that accelerates death.  I'm struggling to understand the distinction, except that the withdrawal of life support restores the patient to a "natural state" and allows nature to take its course, whereas the provision of a prescription to allow a patient to overdose is a commission that seems to interfere with nature.  (Jonathan Baron has written extensively about our preference for "natural states" which often leads to worse outcomes.)  That takes care of the natural versus human distinction (which of course ignores that humans are part of nature), but I still struggle to understand why the patient in Oregon has to administer his own overdose, unassisted by a healthcare professional - what's the difference between a healthcare professional assisting with the administration of an overdose and accelerating death, and his removing life support and thus accelerating death, if both acts are in deference to patient autonomy, and both are commissions, and indeed both are direct actions, as opposed to indirect ones?  Maybe it's because you can act directly and cause harm in respect of autonomy as long as you restore a natural state (withdrawal of life support), but you cannot act directly to cause harm in respect of autonomy by causing an unnatural state (medication overdose).  I think this stream of consciousness has led me to the distinction.  Maybe.  The devil is in the details.