Is it permissible to discontinue ventilator therapy?

From a medical-ethical and legal standpoint, the request to discontinue ventilator therapy and begin palliative care is possible and permissible. By discontinuing the use of the ventilator, the “natural” course of ALS (without medical technology) resumes—the patient is allowed to die. The patient’s expression of intent to discontinue ventilator therapy must be consistently and clearly documented and reiterated during direct doctor-patient interactions.

If the patient is no longer able to communicate, decisions to discontinue ventilator therapy are made in consultation with the health care proxy. The existence of a living will can be highly relevant to the physician’s decision-making process in favor of palliative care. When drafting a living will, it is advisable to distinguish between limiting treatment and discontinuing treatment. Most living will templates currently in use address the refusal of future

“artificial nutrition,” “artificial ventilation,” and “resuscitation” (limitation of treatment). For people with ALS who are already receiving care via a PEG tube or mask ventilation, it is also advisable to establish criteria for when an existing PEG tube, mask ventilation, or invasive ventilation should be discontinued (treatment withdrawal). Accordingly, model advance directives have been developed that address typical decision-making situations regarding treatment limitation and treatment withdrawal in ALS (e.g., available at: www.als-charite.de).