Transcript Document

NAVIGATING DECISIONS ABOUT
LIFE-SUSTAINING TREATMENTS
KRISTEN CHASTEEN MD
PALLIATIVE MEDICINE, HENRY FORD HOSPITAL
OBJECTIVES
• Recognize that eliciting a patient’s values is the first
step in making decisions about life sustaining
treatments
• Describe an overview of common life-sustaining
medical treatments
• CPR
• Mechanical ventilation
• Artificial nutrition and hydration
• Describe some of the risks and benefits of lifesustaining therapies
FACTORS INFLUENCING DECISIONS
Values
Emotions
Decisions about lifesustaining treatments
Faith
Medical facts
RISKS AND BENEFITS
MARY
• 80 year-old woman
• History of diabetes, mild kidney disease and now
has a new diagnosis of early Alzheimer’s dementia
• Hospitalized once in the past year for a serious
bladder infection
• Lives alone in an apartment since her husband died
8 years ago
• Daughter, Julie, lives nearby and visits several times
a week
• Faith is important to her and she is an active
member of a Presbyterian church
VALUES
• Independence
• Recognize and communicate
with family, friends
• Strong faith in God and belief
in miracles also influences
decision making
CARDIOPULMONARY RESUSCITATION
(CPR)
• When Mary was in the hospital last time, the doctor
asked her about her code status
• Full code – in the event of cardiac arrest, CPR
should be attempted
• DNR/DNAR/Do not resuscitate - in the event of
cardiac arrest, CPR should not be
attempted
CARDIAC ARREST
• Loss of heart function, breathing, and consciousness
• The heart's electrical system malfunctions and the
heart stops pumping blood to the rest of the body
• Results in death without immediate treatment
CARDIOPULMONARY RESUSCITATION
(CPR)
• Pressing hard and fast on the center of the chest to
pump blood through the body
CARDIOPULMONARY RESUSCITATION
(CPR)
• CPR also involves
• Pushing oxygen into the lungs by a mask or by inserting a
breathing tube
• Defibrillation
• Intravenous medications
INTUBATION
• Inserting a breathing tube down the mouth into the
windpipe (trachea) and pushing oxygen into the
lungs using a machine called a ventilator
DEFIBRILLATION
• Using electric shocks to restart the heart
INTRAVENOUS MEDICATION
• Putting strong medications like epinephrine into the
vein to help restart the heart
OUTCOMES
• Cardiac arrest out of the hospital
• 10% survival to hospital discharge
• Cardiac arrest in the hospital
• 20% survival to hospital discharge
• ½ of survivors will have minimal or no brain damage
• Patients with lower chance of survival
•
•
•
•
Older, frail, chronic medical illness
Live in a nursing facility
Kidney or liver problems
Widespread (metastatic) cancer
BENEFIT
• Chance of survival to be well enough to leave the
hospital
• Chance of returning to previous health state and
level of functioning
RISKS
• High chance of dying in an ambulance,
emergency room, or intensive care unit (ICU)
• Interferes with family presence at the time of death
• Patient pain and suffering during CPR
• Patient pain and suffering from additional
procedures during an ICU stay after the arrest
• Prolonged dying process may be burdensome for
family
• Chance of survival with brain impairment or
reduced level of functioning
CPR
• http://www.acpdecisions.org/products/videos/
MARY'S CHOICE
MARY
• Mary lives for another 5 years and progresses to
advanced dementia
• Unable to get out of bed
• No longer recognizes friends and family and barely
speaks
• Lives in a skilled nursing facility
• Eating very little
• Transferred to the hospital after developing
pneumonia
VENTILATOR
• A tube is inserted down the mouth into the windpipe (trachea)
and a machine is used to push oxygen into the lungs
• Not able to eat or talk
• Often given sedating medications to ease discomfort
• Tracheostomy: If a ventilator is used long-term, a surgery may
be performed to make a hole in the windpipe (trachea) and
insert a tube to connect to the ventilator
BENEFITS
• Supports breathing while an acute illness (like
infection) is treated
• May allow full recovery to previous health state
• Some people with brain, spinal cord, or nerve
diseases may have breathing problems many years
before the end of their lives and a ventilator may
help them live longer and enjoy additional years of
satisfying life
RISKS
• Someone with advanced incurable illness is much
less likely to survive or return to their previous health
state
• Pain from the breathing tube and other procedures
in the ICU
• Worsening confusion
• Restraints
JULIE SPEAKS FOR MARY
MARY
• Admitted to the hospital
• Given IV antibiotics to treat her lung infection
• Given small doses of morphine to ease her
discomfort from difficulty breathing
• Recovers from her infection, but not able to eat
• A swallowing test shows that when she swallows,
food goes into her lungs
• Julie asks about a feeding tube
TUBE FEEDING
• When a person cannot swallow or is too sick to eat,
a feeding tube delivers liquid nutrition formula
directly into the stomach
• A temporary tube can be placed through the nose
into the stomach (NG tube)
• A long-term tube can be placed by a surgery
through the skin into the stomach or intestines (PEG
tube)
BENEFITS
• For people with a temporary serious illness, a
feeding tube can allow adequate nutrition until
they are able to recover and eat on their own
• For people with a blockage in their throat or
esophagus, a feeding tube may bypass the
blockage
• Some people with brain or nerve diseases may lose
the ability to swallow many years before the end of
their lives and a feeding tube may help them live
longer
RISKS
•
•
•
•
•
Infections
Bleeding
Tube leaking
Diarrhea, cramping
Nausea and vomiting
FOR PEOPLE WITH ADVANCED
DEMENTIA OR AT THE END OF LIFE
• Can cause agitation and cause restraints to be
needed to prevent pulling at the tube
• Do not prevent aspiration of saliva into the lungs or
recurrent lung infections
• Do not extend life
• Can cause swelling in the body, diarrhea, stomach
pain, and fluid in the lungs
ARTIFICIAL HYDRATION
• Medical treatment that provides water and salt
(saline) to someone who is too sick to drink enough
on their own or who has problems swallowing
• Given by an IV in a vein or under the skin
ARTIFICIAL HYDRATION
AT THE END OF LIFE
• People stop drinking as part of the natural dying
process
• People who are very near the end of life usually do
not feel thirst
• Can cause swelling, fluid build-up in the lungs and
back of the throat, nausea or vomiting
MARY
• Enrolls in hospice care and returns to the nursing
home
• Sponge swabs used to prevent dry mouth and
lotion to prevent dry skin
• Small doses of morphine used as needed to
continue to allow her to breath comfortably
• Dies with Julie at her bedside one week later
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improving over time: Results from the resuscitation outcomes consortium (ROC).
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