facts & myths about end-of-life care

Liza Manalo, MDWithholding or Withdrawing Life Sustaining Treatment

MYTHS & FACTS About End-of-Life Choices:

CPR & DNR Palliative Sedation

LIZA C. MANALO, MD, MSc.PALLIATIVE CARE

Philippines

Liza Manalo, MD

MYTH: DNR equals “Do Not Care.” FACT: A DNR order means absolutely

everything will be done up to the point that the patient is found to be in the active dying process. Labs and tests will be done. Antibiotics will be ordered. Patients will go the hospital.

DNR pertains ONLY to the active dying process and not to any other stage.

Withholding or Withdrawing Life Sustaining Treatment

Liza Manalo, MD

MYTH: CPR is usually successful. FACT: CPR frequently can save a person's

life, particularly in the case of some kinds of heart attacks and accidents an otherwise healthy person may experience.

However, when a person is in failing health from a serious and progressive illness, the heart and breathing will ultimately fail as a result of that illness. In such a circumstance, there is little chance that CPR will succeed at all…


Liza Manalo, MD

MYTH: CPR is usually successful. FACT: …Another possibility is that CPR may

be only partially successful. If the heartbeat is restored but a person is still too weak to breathe on his or her own and remains too weak to do so, he or she may be on a ventilator for days, weeks, months or longer.


Liza Manalo, MD

MYTH: CPR can’t hurt. FACT: Pushing the center of the chest down

about one and one-half inches, 100 times a minute for several minutes, causes pain, and may even break ribs, damage the liver, or create other significant problems.

Electric shocks and a tube in the throat are also harsh treatments, but may be essential to resuscitate someone.


Liza Manalo, MD

MYTH: “Doing everything” means we need to do CPR.

FACT: “Doing everything,” means doing everything that is right medically and ethically for that patient at that time. At different times in a patient’s life, different medical interventions are appropriate.

But it can also simply mean respecting the end stage of a disease as the body shuts down and death naturally occurs.


Liza Manalo, MD

MYTH: DNR means that we are abandoning the patient or not providing him or her with every opportunity of life.

FACT: There are times when it may not make sense to perform CPR. There usually comes a time when continued treatment will no longer reduce symptoms nor heal the person and he/she is in an end stage of the disease. Thus, there is little reason to attempt CPR, as CPR may only prolong dying at this point.



Withholding, Withdrawing

Life-Sustaining TreatmentEmanuel LL, von Gunten C J, Ferris FD

Education for Physicians on End-of-Life Care (EPEC) Trainer's Guide,

Module 11: WIthholding, Withdrawing Therapy

.

RICHARD J. ACKERMANN, M.D.Am Fam Physician. 2000 Oct 1;62(7):1555-1560.


Resuscitation (CPR)Elective intubation,

mechanical ventilation

SurgeryDialysis,

HemofiltrationBlood transfusions,

blood products

Diagnostic testsArtificial nutrition,

(parenteral or enteral) or hydration (IVF)

AntibioticsVasopressorsFuture hospital, ICU

admissions

…aimed at maintaining organ function that only prolong death may

be withdrawn or withheld

ANY LIFE-SUSTAINING THERAPY…


Are physicians legally required to provide all life-sustaining measures possible?

No. To the contrary, patients have a right to refuse any medical treatment, even life-sustaining treatments such as mechanical ventilation, or even artificial hydration and nutrition.

- Emanuel LL, von Gunten C J, Ferris. (1999). Education for Physicians on End-of-Life Care Trainer's Guide.


Is withdrawal or withholding of treatment equivalent to euthanasia?

No. There is a strong general consensus that withdrawal or withholding of treatment is a decision that allows the disease to progress on its natural course.

It is not a decision to seek death and end life. Euthanasia actively seeks to end the patient's life.


Liza Manalo, MD

Are you killing the patient when you remove the ventilator and treat the pain?

If the intent is to secure comfort, not death; If the medications are chosen for (and titrated to)

the patient’s symptoms as ventilator weaning proceeds;

If the medications are not administered with the primary intent to cause death,

Then ventilator withdrawal and pain treatment are NOT euthanasia.


Liza Manalo, MD

Usually, actions intended to provide comfort and freedom from unwanted intervention result in a slower progression to death than do actions intended to euthanize.


Are you killing the patient when you remove the ventilator and treat the pain?

Liza Manalo, MD

Can the treatment of symptoms constitute euthanasia?For patients who have been using opioids for

pain, it is in fact very hard to give such high doses of opioids that death is caused (or even hastened) in the absence of a disease process that is leading to imminent death, particularly if accepted dosing guidelines are adhered to.


Liza Manalo, MD

Patients tend to sleep off the effect if they get too much medication.

However, for the rare circumstances when opioids might contribute to death, provided the intent was genuinely to treat the symptoms, then opioid use is not euthanasia.


Can the treatment of symptoms constitute euthanasia?

Liza Manalo, MD

Be careful to avoid the rationale that says, “death is the treatment!”

Symptom treatment alleviates symptoms; it does not intentionally cause death.


Can the treatment of symptoms constitute euthanasia?


Is it illegal to prescribe large doses of opioids to relieve symptoms of pain,breathlessness, or other symptoms?Even very large doses of opioids are both

permitted and appropriate, if the intent and doses given are titrated to the patient’s needs.


Liza Manalo, MD

No. Palliative or terminal sedation of those imminently dying is the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness).


Is palliative or terminal sedation equivalent to euthanasia?

Liza Manalo, MD

Palliative Sedation vs. Euthanasia

In terminal or palliative sedation of those imminently dying: The intention is to relieve intolerable suffering The procedure is to use a sedating drug for symptom

control The successful outcome is the alleviation of distress

In euthanasia:The intention is to kill the patient The procedure is to administer a lethal drugThe successful outcome is immediate death

Materstvedt et al, Palliative Medicine 2003

Liza Manalo, MD

Palliative Sedation

In palliative care, mild sedation may be used therapeutically but in this situation it does not adversely affect the patient’s conscious level or ability to communicate.

The use of heavy sedation (which leads to the patient becoming unconscious) may sometimes be necessary to achieve identified therapeutic goals.

However, the level of sedation must be reviewed on a regular basis and in general used only temporarily.

It is important that the patient is regularly monitored.

Liza Manalo, MD

What does the medical team do when a competent patient has previously refused treatment, but the surrogate decision-maker consents to heroic/aggressive measures when the patient is no longer able to decide for herself? It is essential not to abandon the patient’s family

members, but to work closely with them in determining why they are making decisions that do not appear to be promoting the patient’s best interest.

This exploration, combined with ongoing education by all the members of the health care team, is ethically desirable, in order to make the surrogate decision-maker realize that both he and the medical team have the duty to respect and uphold the patient’s right to self-determination in health care.


HOPEHope lies not only in an expectation of cure or even of the

remission of present distress. For dying patients, the hope of cure will always be shown to be ultimately false, and even the hope of relief too often turns to ashes.

When my time comes, I will seek hope in the knowledge that insofar as possible I will not be allowed to suffer or be subjected to needless attempts to maintain life; I will seek it in the certainty that I will not be abandoned to die alone; I am seeking it now, in the way I try to live my life, so that those who value what I am will have profited by my time on earth and be left with comforting recollections of what we have meant to one another.

- Nuland, Sherwin B (1994). How We Die: Reflections on Life’s Final Chapter


HOPEThere are those who will find hope in faith and their belief in an

afterlife; some will look forward to the moment a milestone is reached or a deed is accomplished; there are even some whose hope is centered on maintaining the kind of control that will permit them the means to decide the moment of their death…

Whatever form it may take, each of us must find hope in his or her own way.

- Nuland, Sherwin B (994). How We Die: Reflections on Life’s Final Chapter


The problem with doctors

Doctors are no more immune to a fear of death than the rest of us, it seems—especially when they see death not as a natural and inevitable outcome of disease, but as a personal defeat or failure.

“It’s frightening for a lot of physicians to deal with dying patients.”

“Physicians find lots of ways to get away from these patients quickly.”

http://www.advancedbc.org/files/ABC Chapter 201 Final Gifts.pdf


Competent Care for the Dying In the real world in which physicians care for dying

patients, withdrawing treatment and aggressively treating pain are acts that respect patients’ autonomous decisions not to be battered by medical technology and to be relieved of their suffering.

- Foley, Kathleen M. (1997). NEJM

Liza Manalo, MD

SUMMARY

Competent patients have the right to make decisions about their own treatment, the right to accept or refuse medical care.

When further intervention to prolong the life of a patient becomes futile, physicians have an obligation to shift the intent of care toward comfort and closure.


Liza Manalo, MD

Withholding or withdrawing life-sustaining therapies is ethical and medically appropriate in these circumstances.

Before reviewing specific treatment preferences, it is useful to ask patients about their understanding of the illness and to discuss their values and general goals of care.


SUMMARY

Liza Manalo, MD

Terminally-ill patients with decision-making capacity can opt to forego any extraordinary medical intervention aimed at maintaining organ function that only prolong death.

If the patient is unable to make his/her own medical decisions and has expressed preferences in the past, the surrogate must use knowledge of these in making end-of-life decisions on behalf of the patient.

Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted.


SUMMARY

Liza Manalo, MD

CONCLUSION

Facilitating decision making and implementing decisions about life-sustaining treatments are essential skills for physicians.

It should be emphasized that each case is unique and there is no single overarching principle that guides end of life decisions.


Liza Manalo, MD

CONCLUSION

No one doctor can claim to have all the answers and patients and their families appreciate truthfulness and sincerity in this regard.

Communication is key to all these types of discussion.

Acceptable clinical practice on withdrawing or withholding treatment is based on an understanding of the medical, ethical, cultural, and religious issues.


Liza Manalo, MD

CONCLUSION

There is a need to individualize care option discussions to illness status, and patient and family preferences, beliefs, values, and cultures.

Shared decision-making on treatment preferences should be periodically revisited as the goals evolve and change over time.


Liza Manalo, MD

FURTHER READINGEnd-of-Life Decisions about Withholding or

Withdrawing Therapy: Medical, Ethical, and Religio-Cultural Considerations, Palliative Care: Research and Treatment 2013:7 1-5

doi: 10.4137/PCRT.S10796

Manalo, MFC, (Mar 2013)

http://www.la-press.com/end-of-life-decisions-about-withholding-or-withdrawing-therapy-medical-article-a3582


http://dx.doi.org/10.4137/PCRT.S10796







“It's only when we truly know and understand that we have a limited time on earth and that we have no way of knowing when our time is

up, we will then begin to live each day to the fullest, as if it was the only one we had.”

- Elisabeth Kubler Ross

“We have to ask ourselves whether medicine is to remain a humanitarian and

respected profession, or a new but depersonalized science in the service of prolonging life rather than diminishing

human suffering.”

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