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| Colorado Gerontological Society and Senior Answers and Services | |
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| End-of-life Care
or Medical Treatment A Starting Place for Discussion: Information compiled by Susan Malmstadt |
| Facing decisions
about end-of-life care or medical treatment for a sick or dying loved one is extremely
difficult and often confusing for families and caregivers. The Colorado Collective for
Medical Decisions (CCMD) provides knowledge that will help families and caregivers talk to
each other and to health care professionals during times of such emotional stress. The
following information is excerpted from three pamphlets created by CCMD with funding
provided by The Colorado Trust. The pamphlets explain Tube-Feeding, Mechanical Ventilation
and Cardiopulmonary Resuscitation (CPR) - issues everyone needs to understand to make
informed decisions in the face of serious medical illness. Important Terms Before making an informed decision for yourself, a loved one or a patient in your care, you need to know the meaning of these terms: Advance Directive: A general term describing a variety of legal instructions people can sign to express their wishes about future medical treatment. In Colorado, these include a living will, a medical durable power of attorney and a CPR Directive. Cardiopulmonary Resuscitation (CPR) Directive: An advance directive that tells emergency medical teams not to use CPR. The Colorado Department of Public Health and Environment issues paper CPR directive forms, which a patient can use to purchase a state CPR directive necklace or bracelet. Do Not Resuscitate Order: A doctor’s order written in the patient’s medical chart telling hospital or nursing home staff not to resuscitate the patient if he or she has a cardiac arrest or stops breathing. Comfort Care: Treatment aimed at relieving the physical, emotional and spiritual distress that is often part of the dying process. The goal is not to cause death, but to permit death to occur as gently, comfortably and as painfree as possible. Hospice: Care provided to terminally ill patients and their families by an interdisciplinary team working in conjunction with a physician. The goal of the team is to provide comfort care either at home, in assisted living and nursing facilities, in hospitals and in hospice care centers. Living Will: A signed document stating that a person does not want artificial life support if he or she becomes terminally ill and can no longer communicate. A living will applies only to artificial life support during terminal illness and does not include other medical treatment. It can also apply to tube-feeding. Medical Durable Power of Attorney: A document signed by a patient appointing another person as an "agent" who will make medical treatment decisions for the patient, if he or she cannot communicate. About Cardiopulmonary Resuscitation (CPR) The most common form of CPR uses "mouth to mouth" breathing to transfer oxygen by pressing on the patient’s chest to stimulate the lungs and heart. Trained personnel doing CPR can use electric shock, airway tubes, fast-acting medications and other procedures called "advanced cardiac life support." CPR can be very helpful for patients who suffer a sudden accident and are otherwise healthy and expected to regain physical and mental functioning. At times, a person who is resuscitated may not be able to fully recover or resume previous activities. This happens when resuscitation is administered too late, or the brain has been without oxygen for so long that serious, permanent nerve damage and/or mental impairment occurs. Sometimes using CPR has other side effects, like broken ribs or damage to the windpipe. CPR can be a lifesaving measure for an otherwise healthy person, but it can be abused or "overdone" if the person receiving CPR is too sick or frail to recover. Many people who are already in very poor health do not want CPR to interrupt their natural dying process. In this case, they should have a CPR directive, which tells emergency medical teams not to use CPR. In a medical facility, a doctor’s order can be written in the patient’s medical chart. It tells the staff that the patient should not be resuscitated if he or she has a cardiac arrest or stops breathing. About Tube Feeding Tube feeding is a method of delivering liquid and nutrients to patients who cannot eat or drink by mouth. For short term tube-feeding, a lengthy tube is usually inserted through the patient’s nose and esophagus into the stomach. For long-term tube-feeding, a tube may be inserted directly through the skin into the stomach or the intestines. A tube into the stomach is called a gastric or "G" tube, and a tube into the intestines is called a jejunal or "J" tube. Another form of long-term artificial feeding is "total parenteral nutrition" (TPN). With TPN, liquid nutrients flow through a small plastic tube (catheter) directly into a large vein near the patient’s heart. Short term tube-feeding may help a patient survive and regain the ability to eat and drink naturally. It can maintain life when administered during recovery from an operation, an accident or serious illness. Tube-feeding can also build up a patient’s strength before surgery. On the other hand, feeding tubes do have serious risks. They can cause pneumonia, infection and discomfort. In some circumstances, they make no difference in a patient’s survival. Moreover, patients who try to remove the tubes can injure themselves or have to be physically or chemically restrained. Many terminally ill patients who voluntarily abstain from using tube-feeding report that they are more comfortable and experience less pain than tube-fed patients. The outcome of using tube-feeding generally depends on the patient’s condition. In a study of 1386 nursing home residents aged 65 and over with advanced dementia, there was no difference in survival with or without tube-feeding. Patients with advanced illnesses such as Alzheimer’s Disease or cancers do not feel hunger or thirst and their appetites naturally diminish as death approaches. Short-term "trial periods" of tube feeding can sometimes show whether longer periods will lead to recovery or just prolong the patient’s death. About Mechanical Ventilation A ventilator, sometimes called a respirator, is a machine that pumps oxygen into and out of a patient’s airway and lungs. It is a mechanical substitute for normal breathing. Though not a cure in itself, a ventilator can "buy time" to see if the patient can resume breathing naturally. Patients can receive mechanical ventilation in three ways: through an endotracheal tube, through a tracheostomy and through a face mask. An endotracheal tube is a plastic tube passed through the patient’s nose or mouth into the windpipe. The tube is connected to a breathing machine that pumps air through the tube into the patient’s airway. This method is generally used for short-term ventilation. For a tracheostomy, the patient undergoes surgery to make a small opening in the patient’s neck. A short tube is inserted through the opening directly into the windpipe and the tube is connected to a breathing machine, which pumps air through the tube into the patient’s airway. A patient on any type of mechanical ventilator must either lie in a bed or sit on a chair with restricted movement. With an endotracheal tube, the patient is unable to speak or swallow. Providing ventilation through a face mask is called "non-invasive positive pressure ventilation." With this short-term technique, a mask is strapped over the patient’s nose and oxygen is pumped through the airway. This method is sometimes used to help a patient through a short-term, acute episode. Though patients may have some ability to speak or swallow, others find the treatment uncomfortable. Sometimes this procedure is unsuccessful and it does not always provide adequate ventilation. When patients’ lungs and breathing functions improve, they can sometimes be "weaned" from the ventilator and gradually begin breathing on their own. For those who cannot recover, stopping the ventilator leads to a natural death. Drugs and comfort measures can then be offered to prevent patients from experiencing pain or distress while dying. Mechanical ventilation can save lives when it is used for patients recovering from short-term illness or accident. It is also used during surgeries to keep patients breathing during general anesthetic. Mechanical ventilation cannot cure a permanent coma or restore a patient’s lungs or prevent death when a person has an incurable, fatal disease. Patients on mechanical ventilators are also at increased risk for pneumonia because they cannot cough effectively and fluids can build up in their lungs. CPR, Tube-Feeding and Mechanical Ventilation can all be used short-term to show whether longer periods will lead to recovery or just prolong death. The decision to use any of them depends on many factors including the patient’s state of health, chances of recovery, will to live and the benefits and burdens of further treatment. There are no black and white answers about whether these treatments are appropriate. Each situation is different.
This information is provided by the Colorado Collective for Medical Decisions (CCMD), 777 Grant Street, Suite 206, Denver, 80203. Phone 303-788-1198. E-mail: ccmdco@aol.com. Contact Hospital Shared Services of Colorado to order multiple copies of the brochures "As You Think About Mechanical Ventilation," "As You Think About Cardiopulmonary Resuscitation (CPR)" and "As You Think About Tube-Feeding." Attention: Stockless Forms Management, 1890 W. 32nd Ave, Denver, CO 80521. Phone 303-455-1420. Helpful Resources: Colorado Hospice Organization (CHO) |
