| Issues to
Consider When Completing Advance Directives
Cardiopulmonary Resuscitation (CPR)
Cardiopulmonary resuscitation (CPR) is a combination of
rescue breathing and chest compressions delivered to victims
thought to be in cardiac arrest. When cardiac arrest
occurs, the heart stops pumping blood. CPR can support a
small amount of blood flow to the heart and brain to “buy
time” until normal heart function is restored. Statistics
show that fewer than 30% of those who receive CPR survive if
the procedure is begun within four minutes after the heart
stops. If begun after four minutes, the survival rate drops
to 7%.
CPR has the
following associated risks:
-
A frail victim’s ribs could
be broken and a lung punctured because of the necessary
force applied during CPR.
-
If too much time has elapsed
since the victim has been without oxygen, brain damage
can occur.
-
The chain of
events put into motion through the initiation of CPR,
could cause someone to be placed on a respirator even
though they might not have wanted it.
-
A terminally
ill individual has virtually no chance of surviving a
cardiac arrest.
In health
care facilities, it is generally assumed that every patient
will receive CPR if the person’s heart stops. Therefore, a
DNR order must be issued by the physician if this is not
what the patient would want to occur.
Mechanical Respiration
(Ventilation)
Sometimes after CPR is
initiated, the heart may start beating but breathing may not
resume. This is known as respiratory failure. If this
occurs, a machine called a respirator or ventilator can take
over breathing if the lungs cannot function adequately,
providing oxygen through a tube inserted in the windpipe.
This is known as mechanical respiration (ventilation).
Sometimes respirators can
pull a person through a serious illness from which they are
expected to recover. However; in some cases, especially in
the seriously ill, breathing may never be fully restored and
the person becomes permanently dependent on the respirator.
There are effective medical
interventions (oxygen, muscle relaxants, narcotics) that can
ease distressing symptoms if a person does not want to be
placed on a respirator or if they or their family want them
removed from a respirator.
Artificial Feeding & Hydration
When a patient can no longer
take food or fluid by mouth, feeding tubes and intravenous
lines can be used to provide artificial nutrition and
hydration.
Artificial hydration is when
intravenous lines are used to provide fluids (hydration).
This is only a temporary measure, and is not meant
to be a long-term solution. The risks associated with
artificial hydration include:
-
For patients without permanent venous access, the
repeated placement of intravenous may be difficult and
painful due to the fragility of their veins.
- The
patient may develop edema (when the body tissue retains
fluid) because their body cannot tolerate the extra
fluids.
- The
patient may develop respiratory distress or cardiac
overload when their heart is unable to circulate the
excess fluid around their body.
Artificial Feeding is
done through feeding tubes, which come in two types:
1. A nasogastic tube
(NG) is inserted through the nose, down the esophagus and
into the stomach. This tube is not meant to be used for
longer than 30 days. Risks include:
-
Discomfort for the patient, as a result of the presence
of the tube.
-
Pneumonia can develop if regurgitated fluid enters the
lungs.
2. A gastrostomy tube
is inserted surgically through the skin into the stomach
wall. Liquid nutritional supplements, water and medications
can be poured or pumped into the tube. Risks include:
-
Patient may need to be restrained so they do not pull
the tube out.
- Ulcers
around the site of the tube and infections can develop.
- A
patient’s body may not be able to tolerate the feedings
and the feedings are regurgitated through the tube.
Patient’s with either type of
feeding tube will require special care from a family member
or other caregiver to administer the feedings and manage the
care of the feeding tube. Depending upon the individual
situation, the placement of these tubes may necessitate the
individual being placed in an institution because there is
no one available to provide the care in a home setting.
Prior to placement of the tube, thought should be given as
to how the patient’s care needs will be addressed after the
tube is placed.
Many consider the use of
artificial tubes to be an extraordinary measure. They argue
that this is equivalent to force feeding and is more of a
burden than a benefit to those people who are seriously ill
or in an irreversible coma. For those individuals with a
serious illness, the placement of a feeding tube will not
stop the progression of the illness. Some people are
concerned that if artificial feeding or hydration is not
provided, it is equivalent to starving someone to death.
Others see the inability to
take food and water by mouth as a terminal medical
condition. They believe that withholding or withdrawing
artificial feeding and/or hydration is to allow a natural
death to occur and thus not prolonging the dying process.
Antibiotics
Antibiotics are medications
used to fight infections. Antibiotics can provide comfort
if the infection itself causes discomfort to a conscious
patient but they do not always prevent death due to serious
infection. Other facts to consider with the use of
antibiotics include:
-
Infections sometimes clear up even if antibiotics are
not given.
- Fever
and other symptoms of infection can often be treated
without antibiotics.
- Allergic
reactions, diarrhea and kidney failure can occur from
the use of antibiotics.
In the seriously ill,
infection may be the precipitating factor that leads to
death, i.e. pneumonia in a person who has lung cancer.
Serious infection in the seriously ill can lead to sleep or
coma and may be the body’s way of producing a peaceful
death. Some believe that treating an infection with
antibiotics may only serve to prolong death.
Dialysis
Dialysis is the use of a
machine to cleanse the blood of toxins when the kidneys
cannot function adequately. The procedure takes several
hours and is usually performed several times a week. Many
people with chronic kidney failure undergo regular dialysis
for years and tolerate the procedure well. However,
dialysis has the following associated risks:
- Dialysis
can be very uncomfortable for the patient.
- Total
kidney failure can eventually produce cardiac failure or
coma.
When kidney failure is
combined with, or is the result of, another serious illness,
dialysis does not improve the underlying condition. Some
believe it only prolongs death.
Diagnostic Tests
You may wish to state in your
advance directives that if you were seriously ill, you would
want to refuse all but the simplest tests or any testing
that would not change the treatment you would receive to
keep you comfortable.
Comfort Care
Comfort
care is any kind of treatment that increases a person’s
physical or emotional comfort. It generally does not
involve advanced technology. It can include oxygen, food
and fluids by mouth, turning and positioning, and
medications to relieve distressing symptoms. Many people
state in their Living Will
or Health Care Proxy,
that they want any medication that will reduce or eliminate
their suffering even if it has the unintended consequence of
hastening their death.
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