The End of Life: Medical Considerations - Life-sustaining Treatments

Life-sustaining treatments, also called life support, can take over many functions of an ailing body. Under normal conditions, when a patient suffers from a treatable illness, life support is a temporary measure used only until the body can function on its own. The ongoing debate about prolonging life-sustaining treatments concerns the incurably ill and permanently unconscious.

Cardiopulmonary Resuscitation

Cardiopulmonary resuscitation (CPR) is composed of two basic life-support skills administered in the event of cardiac or respiratory arrest: artificial circulation and artificial respiration. Cardiac arrest may be caused by a heart attack, which is an interruption of blood flow to the heart muscle. A coronary artery clogged with an accumulation of fatty deposits is a common cause of interrupted blood flow to the heart. Respiratory arrest, on the other hand, may be the result of an accident such as drowning, or the final stages of a pulmonary disease such as emphysema.

In CPR artificial circulation is accomplished by compressing the chest rhythmically to cause blood to flow sufficiently to give a person a chance for survival. Artificial respiration is accomplished by breathing into the victim's nose and mouth. It is important that CPR be done properly, or it may not be effective and may harm the victim. Heath care professionals may go beyond typical CPR procedures and deliver oxygen directly into the lungs through a tube inserted down the trachea (windpipe). Rarely, a tracheotomy is performed. In this procedure an opening is made in the windpipe through which a breathing tube is inserted. Electrical shock and medication may also be used to "jump start" the heart.

CPR, initially intended for healthy individuals who unexpectedly suffered heart stoppage, is now widely used in a variety of circumstances. While CPR does not always work (it has a 20-50% success rate in healthy people), it does help save lives. Generally, following CPR, healthy people eventually resume normal lives. The outcome is quite different, however, for patients in the final stages of a terminal illness. Nancy Dubler and David Nimmons (Ethics on Call, New York: Harmony Books, 1992) observe that for people with a terminal disease, dying after being "successfully" resuscitated virtually ensures a slower, harder, more painful death.

REFUSAL OF CPR WITH A DO-NOT-RESUSCITATE ORDER

A person not wishing to be resuscitated in case of cardiac or respiratory arrest may ask a physician to write a DNR order on his or her chart. This written order instructs health care personnel not to initiate CPR, which can be very important because CPR is usually performed in an emergency. Even if a patient's living will includes refusal of CPR, emergency personnel rushing to a patient have no time to check the living will. A DNR order on a patient's chart is more accessible.

NONHOSPITAL DNR ORDERS

Most hospitals have policies governing DNR orders in the event a patient has no advance directives refusing CPR. (An advance directive is a written document stating how you want medical decisions to be made if you lose the ability to FIGURE 4.1 State laws governing nonhospital do-not-resuscitate (DNR) orders, 2004 "State Laws and Protocols Governing Nonhospital Do-Not-Resuscitate (DNR) Orders," in End-of-Life Law Digest, The National Hospice and Palliative Care Organization, 2004make those decisions for yourself.) Outside the hospital setting, such as at home, people who do not want CPR performed in case of an emergency can request a non-hospital DNR order from their physicians. (See Figure 4.1 for a map of the United States showing states that had laws authorizing nonhospital DNR orders as of January 2004.) Also called a pre-hospital DNR order, it instructs emergency medical personnel to withhold CPR. The DNR order may be on a bracelet, necklace, or a wallet card. However, laypersons performing CPR on an individual with a nonhospital DNR order cannot be prosecuted by the law.

Mechanical Ventilation

When a patient's lungs are not functioning properly, a ventilator, or respirator, breathes for the patient. Oxygen is supplied to the lungs through a tube inserted through the mouth or nose into the windpipe. Mechanical ventilation is generally used to temporarily maintain normal breathing in those who have been in serious accidents or who suffer from a serious illness, such as pneumonia.

Today, a person who suffers cardiac or respiratory arrest is attached to a respirator after CPR has restarted the heart. In some cases, if the patient needs ventilation indefinitely, the physician might perform a tracheotomy to open a hole in the neck for placement of the breathing tube in the windpipe. Even if a patient has irreversible brain damage, as long as the brain stem is functioning, the person is considered alive and the mechanical respirator cannot be withdrawn.

Ventilators are also used on terminally ill patients. In these cases the machine keeps the patient breathing but does nothing to cure the disease. Those preparing a living will are advised to give clear instructions about their desires regarding continued use of an artificial respirator that could prolong the process of dying.

Artificial Nutrition and Hydration

Artificial nutrition and hydration (ANH) is another modern-day technology that has further complicated the dying process. Today, nutrients and fluids supplied intravenously or through a stomach or intestinal tube can indefinitely sustain the nutritional and hydration needs of comatose and terminally ill patients. ANH has a strong emotional impact because it relates to basic sustenance. In addition, the symbolism of feeding can be so powerful that families who know that their loved one would not want to be kept alive may still feel that not feeding is wrong. However, appetite loss is common in dying patients and is not a significant contributor to their suffering. As discussed in "Artificial Nutrition and Hydration and End-of-Life Decision Making" (National Hospice and Palliative Care Organization, 2005, http://www.caringinfo.org/files/public/QA_artificial_Nutrition_booklet.pdf), the withdrawal of ANH from a dying patient does not lead to a long and painful death. Moreover, evidence exists that avoiding ANH contributes to a more comfortable death.

ANH has traditionally been used in end-of-life care when patients experience a loss of appetite and difficulty swallowing. Health care practitioners use ANH to prolong life, prevent aspiration pneumonia (inflammation of the lungs due to inhaling food particles or fluid), maintain independence and physical function, and decrease suffering and discomfort. However, artificial nutrition and hydration do not always accomplish these goals, as noted in the Hospice and Palliative Nurses Association (HPNA) position paper "Artificial Nutrition and Hydration in End-of-Life Care" (Home Healthcare Nurse, vol. 22, no. 5, May 2004). The position paper points out that results of studies "show that tube feeding does not appear to prolong life in most patients with life-limiting, progressive diseases; moreover, complications from tube placement may increase mortality. Furthermore, artificially delivered nutrition does not protect against aspiration and in some patient populations may actually increase the risk of aspiration and its complications."

The American Dietetic Association (ADA) has taken the formal position that "the development of clinical and ethical criteria for the nutrition and hydration of persons through the life span should be established by members of the health care team. Registered dietitians should work collaboratively to make nutrition, hydration, and feeding recommendations in individual cases" ("Position of the American Dietetic Association: Ethical and Legal Issues in Nutrition, Hydration, and Feeding," Journal of the American Dietetic Association, vol. 102, no. 5, May 2002). The ADA suggests that the patient should determine the extent of his or her nutrition and hydration, and that shared decision making should occur between health care professionals and the family when the patient cannot make such decisions.

Kidney Dialysis

Kidney dialysis is a medical procedure by which a machine takes over the function of the kidneys in removing waste products from the blood. Dialysis can be used when an illness or injury temporarily impairs kidney function. It may also be used by patients with irreversibly damaged kidneys awaiting organ transplantation.

Kidney failure may also occur as an end-stage of a terminal illness. While dialysis may cleanse the body of waste products, it cannot cure the disease. People who wish to let their illness take its course may refuse dialysis. They will eventually lapse into a coma and die.