Life: To prolong or not to prolong
Modern Medicine provides many a machine, device and procedure that can extend life and improve its quality. Coronary (heart) Bypass Surgery, and implantable cardiac devices (eg pacemakers) are but two examples that give longer life for those who might have died in their 60’s – as was the case in previous generations.
When bodies and brains are able to fully recover, deciding factors about life-prolonging medical interventions (life support) can be completely different than when the body is winding down, or the brain no longer functions.
“Life support replaces or supports a failing bodily function. When patients have curable or treatable conditions, life support is used temporarily until the illness or disease can be stabilized and the body can resume normal functioning. At times, the body never regains the ability to function without life support.”
Decisions to use machinery, devices and interventions to support or prolong life – or not to prolong – life are rarely without emotion
‘When making decisions about specific forms of life support, gather the facts you need to make informed decisions. In particular, understand the benefit as well as the burden the treatment will offer you or your loved one. A treatment may be beneficial if it relieves suffering, restores functioning, or enhances the quality of life. The same treatment can be considered burdensome if it causes pain, prolongs the dying process without offering benefit, or adds to the perception of a diminished quality of life. A person’s decision to forgo life support is deeply personal. When gathering information about specific treatments, understand why the treatment is being offered and how it will benefit your care cleveland clinic: Understanding Life Support Measures
Questions to consider when considering life support:
- Will intervention allow one live longer, or possibly die sooner
- How long will it take to recover
- Will quality of life improve, be maintained or worsen
- Will it likely cure underlying illness
Supporting and Prolonging Life: It’s complicated
Take into account the complications that can arise as a result of some of these interventions:
- severe agitation.
- Discomfort and pain, requiring medication
- Overall weakening of a ‘system’ already weakened.
Cardio Pulmonary Resuscitaton: one of many interventions
While CPR may be the best known ‘intervention’, or ‘heroic measure’, other common causes of decisional distress:
Feeding via ‘tubes’
The decision to start supplemental feeding – via NG (down the nose)or PEG (via tube inserted into the abdomen) is different for different medical situations: when recovering from surgery or sudden illness, for neurological conditions like ALS as well as healthy patients who require long-term nutritional support.
But for the elderly, as life winds down, feeding tubes can cause many an unwanted problem, from:
- ‘food’ getting into the lungs and causing pneumonia (aspiration pneumonia)
- Infections from having a foreign body in your body
- Retaining fluid, causing painful swelling
- Uncomfortable enough to warrant being restrained to prevent dislodging
For those with Dementia who have trouble swallowing, tube feeding can be is particularly dangerous – possibly causing aspiration pneumonia (when food is inhaled into the lungs), bed sores – often those with Dementia and feeding tubes need to be restrained to keep the tube in place, and are therefore bed-bound.
Breathing Machines (Ventilators) and tubes down the throat (intubation)
Many neurological (brain) and breathing-related conditions may require living on a ventilator (breathing machine). This is attached to a tube inserted in the nose or mouth (intubation) and down into the windpipe (or trachea). Often this also requires a hole to be cut in the windpipe (tracheotomy) with medication to sedate and relieve pain.
Dr Balfour Mount, credited with introducing Palliative Care in Canada:
I have had a permanent tracheostomy for seven years. With each breath I take I realize that I may not be able to take the next one because it takes a remarkably small amount of secretions to block the tube.
The decision to introduce mechanical breathing as life winds down should take into account that prolonging life does not equal improving life quality of life. Instead it’s been described as prolonging dying.
“Sometimes people are too weak or their illness is so progressed that they will never be able to breathe again on their own. The patient then faces the possibility of remaining on the machine for the rest of his/her life.Even people who have not discussed end-of-life issues may have expressed the desire to not be kept alive “on a machine;” generally, it is a ventilator they are referring to when they say this. Consider if you would want mechanical ventilation if you would never regain the ability to breathe on your own or return to a quality of life acceptable to you.”
Many who live with kidney failure and end stage renal (kidney) disease benefit from dialysis and the quality of life they experience as a result, outweigh the burdens of dialysis. But for some people, the opposite is true – the burdens of dialysis outweigh the benefits. As life is winding down, the option is to consider the short and long term impact on the quality of life, and the quality of death without dialysis.
Implanted Cardiac Devices
Other medical miracles, for those living with heart failure are pacemakers and Implantable-cardioverter defibrillators (ICDs). While life-saving in the event of a heart problem in an otherwise healthy body, these devices give nasty shocks in a body that’s winding down If the decision is Not to Revive (DNR) it’s important to include directing the ICD be de-activated.
“The definition of a ‘minor procedure’: Something that happens to someone else”