ISSUE #15
 
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WITHDRAWING ECMO OR STOPPING DIALYSIS TREATMENTS FOR A TERMINALLY ILL PATIENT
 
QUESTION: 

Is it permissible to withdraw ECMO or stop dialysis for a terminally ill patient?

ANSWER:

Any decision that impacts the dying process of an end-of-life patient must always be referred to an expert Rabbi who will consult with the medical team, analyze the complex issues involved, weigh the individual circumstances, and issue guidance according to halacha (Jewish law). One of the fundamental principles relevant to this topic is the halachic distinction between active and passive causation. Thus, for example:
  1. From a halachic perspective, actively hastening the demise of a patient is always considered extremely problematic. 
  2. In contrast, passively abstaining from prolonging the patient's death is not viewed in the same manner, and may sometimes be permissible.
In light of this distinction, let us now take a look at the question of withdrawing ECMO or stopping dialysis treatments for a terminally ill patient.
 
ECMO:
 
"ECMO" stands for "extracorporeal membrane oxygenation." It is a lifesaving invasive therapy that temporarily replaces the function of the heart and lungs, by pumping and supplying oxygen to the patient's blood from outside his or her body.
 
ECMO is considered a highly-aggressive and risky treatment, which is used as a last resort when other, less risky options for the patient have been ruled out. ECMO does not cure the patient's heart or lungs; instead, it is a temporary measure to keep the patient alive so that his/her body has more time to heal itself.
  • Like a ventilator, ECMO is a continuous life-support treatment therapy. For a patient who has not healed from the underlying condition that led to the initiation of ECMO, withdrawal of ECMO certainly causes the patient to die more quickly.
  • Some medical professionals and/or secular ethics or law may not consider withdrawal of ECMO for such a patient as euthanasia or physician-assisted suicide. (See this article for example, which states without qualification that "ECMO physicians and technicians counsel families that "if it's very clear we are simply prolonging the process of dying, we stop."
  • HOWEVER, from the perspective of halacha (Jewish law), any action that directly withdraws ECMO - or a ventilator, or any similar type of continuous life-support - from a patient whose life relies upon it, is an action that has terminated a life; thus, halacha views any such action as being extremely problematic.
  • Nevertheless, in some cases it may be very difficult to continue ECMO when doctors do not anticipate the likelihood of the patient's recovery, especially when the patient appears to be suffering significantly. Consequently, in many cases of a terminally ill patient, it may sometimes be more advisable to avoid this quandary by considering abstaining from initiating ECMO in the first place.
In conclusion therefore, patients and families are very strongly advised to request a consultation between the medical team and an expert Rabbi before initiating ECMO, if at all possible. If the patient is already on ECMO, then an expert Rabbi must be consulted before withdrawal of ECMO may be considered.

DIALYSIS:
 
Like ECMO, dialysis is a lifesaving invasive therapy. 

The role of dialysis is to mimic the function of a human kidney by removing blood from the patient's body, eliminating waste material and excess fluid from the blood, and then reintroducing it into the body.
  • If a patient with kidney failure refuses dialysis, the waste product and toxins and extra water will pile up in his/her blood. If their level is too high, they can cause many other diseases and symptoms, such as heart failure, nausea, vomiting, shortness of breath. Thus, stopping dialysis treatments may certainly lead to the patient dying more quickly.
  • NEVERTHELESS, from the perspective of halacha, there is a major distinction between stopping dialysis treatments and withdrawing ECMO: Whereas ECMO is a continuous life-support treatment, dialysis consists of a series of separate treatments (many patients receive 2-3 treatments per week, but some may receive treatments as often as daily). Therefore, unlike withdrawal from ECMO, stopping dialysis is accomplished passively and does not involve any action.

Consequently, if a patient is suffering greatly or there are other overwhelming reasons to (passively) stop the patient's dialysis treatments, there may be room in halacha for this to be permissible. As always, patients and family members must consult an expert Rabbi who will take into account the patient's individual circumstances and issue halachic guidance accordingly.

 
 
For over two decades, CMC has been counseling patients and family members throughout the Chicago area concerning end-of-life issues such as those mentioned above. CMC connects patients and families with local Rabbonim who are expert in the end-of-life field, so that they may be reassured of having authoritative halachic answers that are tailored to their specific individual circumstances.

To request CMC guidance and/or support regarding an end-of-life issue or for any patient and/or family member struggling with illness, please call CMC or click this link to visit CMC's website.
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Rabbi Aron Wolf
Chicago Mitzvah Campaign
2939 W Touhy Ave
Chicago, IL 60645
1-866-MY RABBI (1-866-697-2224)