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 to 50 percent 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 since 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
FIGURE 4.1
State laws governing Do Not Resuscitate (DNR) orders, 2004
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 make 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 nonhospital 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 are other modern-day technologies that have further complicated the dying process. Today, nutrients and fluids supplied intravenously or through a stomach or intestinal tube can indefinitely sustain comatose and terminally ill patients. These processes have strong emotional impacts, relating as they do to basic sustenance. Partnership for Caring, Inc., an organization "dedicated to fostering communication about complex end-of-life decisions among individuals, their loved ones, and health-care professionals," explains in their September 2000 fact sheet "Artificial Nutrition and Hydration: Comfort Care or Medical Treatment?":
Normally, feeding a helpless person—a baby, an invalid—is a lifesaving and deeply caring act. When someone is dying and there is "nothing more to be done," that urge may become even stronger. The desire to show our caring often reflects a sense of powerlessness in the face of death.
It's one thing when a competent dying person refuses tube feeding and can explain her choice, while reassuring her loved ones that she's not in pain. It's another to make that decision for someone who is unconscious or incompetent.
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 stopping feeding is taboo.
In January 2004, Partnership for Caring merged with Last Acts, an organization that works to elevate awareness and action about needed improvements in end-of-life care. In addition to providing information on death and dying for both consumers and health care professionals, the organization's mission is to advocate policy reform.
Robert M. McCann, et al., in "Comfort Care for Terminally Ill Patients: The Appropriate Use of Nutrition and Hydration" (Journal of the American Medical Association, vol. 272, no. 16, October 26, 1994), observed that while there is a widespread assumption that artificial nutrition and hydration add to the well-being of patients—especially those who are mentally competent—there are no clinical data to support this assumption.
Researchers studied 32 terminally ill patients from their admission until their death in a comfort care unit. Most were diagnosed with cancer or stroke. The patients were offered food, and fed if necessary, but were never forced to eat. Pain was relieved with drugs, but not to the point of sedation. Several times each day, the health team assessed patients' discomfort from hunger or thirst by asking them and their families about pain, shortness of breath, nausea, fears, and anxiety. If the patient became unconscious before dying, the family and the health team assessed patient comfort by observing signs, such as grimacing, moaning, and constant tossing and turning.
Twenty of the 32 patients (63 percent) reported no hunger. Eleven patients (34 percent) who initially reported being hungry during the first quarter of their stay eventually lost their appetites. Those who were hungry needed only a very small amount of food. Thirst was more common, with twenty-one patients (66 percent) reporting it. Nine experienced thirst initially, while twelve reported being thirsty until they died. Families and the health team administered sips of liquid, ice chips, and hard candy, as well as lip moisteners and mouth care to alleviate thirst. The researchers observed that the decreased liquid intake resulted in fewer cases of prolonged choking and suctioning of patients.
McCann and his colleagues further pointed out that artificial nutrition and hydration are usually initiated more to relieve the anxiety of caregivers and patients' families than to benefit the patient. Competent patients have been known to refuse artificial feeding during the final stages of their illness. In this study, nine of the patients who ate to please their families experienced nausea and stomach discomfort. Appetite loss is common in dying patients and is not a significant contributor to their suffering.
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.
TABLE 4.4
Comparison of clinical features associated with coma, vegetative state, minimally conscious state, and Locked-in Syndrome
| Condition | Consciousness | Sleep/wake | Motor function | Auditory function | Visual function | Communication | Emotion |
| Coma | None | Absent | Reflex and postural responses only | None | None | None | None |
| Vegetative state | None | Present | Postures or withdraws to noxious stimuli | Startle | Startle | None | None |
| Occasional nonpurposeful movement | Brief orienting to sound | Brief visual fixation | Reflexive crying or smiling | ||||
| Minimally conscious state | Partial | Present | Localizes noxious stimuli | Localizes sound location | Sustained visual fixation | Contingent vocalization | Contingent smiling or crying |
| Reaches for objects | Inconsistent command following | Sustained visual pursuit | Inconsistent but intelligible verbalization or gesture | ||||
| Holds or touches objects in a manner that accommodates size and shape | |||||||
| Automatic movements (e.g., scratching) | |||||||
| Locked-in syndrome | Full | Present | Quadriplegic | Preserved | Preserved | Aphonic/anarthric | Preserved |
| Vertical eye movement and blinking usually intact | |||||||
| SOURCE: J. T. Giacino et al., "Table Comparison of Clinical Features Associated with Coma, Vegetative State, Minimally Conscious State, and Locked-in Syndrome," in "The Minimally Conscious State: Definition and Diagnostic Criteria," Neurology, vol. 58, no. 3, February 12, 2002 | |||||||
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.
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