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K R I S T E N C H A S T E E N M DP A L L I A T I V E M E D I C I N E , H E N R Y F O R D H O S P I T A L
NAVIGATING DECISIONS ABOUT LIFE-SUSTAINING TREATMENTS
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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 life-sustaining therapies
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FACTORS INFLUENCING DECISIONS
Values
Faith
Emotions
Medical facts
Decisions about life-sustaining treatments
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RISKS AND BENEFITS
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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
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VALUES
• Independence• Recognize and communicate with family, friends• Strong faith in God and belief in miracles also influences decision making
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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
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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
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CARDIOPULMONARY RESUSCITATION (CPR)
• Pressing hard and fast on the center of the chest to pump blood through the body
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CARDIOPULMONARY RESUSCITATION (CPR)
• CPR also involves• Pushing oxygen into the lungs by a mask or by inserting
a breathing tube• Defibrillation• Intravenous medications
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INTUBATION
• Inserting a breathing tube down the mouth into the windpipe (trachea) and pushing oxygen into the lungs using a machine called a ventilator
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DEFIBRILLATION
• Using electric shocks to restart the heart
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INTRAVENOUS MEDICATION
• Putting strong medications like epinephrine into the vein to help restart the heart
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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
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BENEFIT
• Chance of survival to be well enough to leave the hospital• Chance of returning to previous health state and
level of functioning
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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
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CPR
• http://www.acpdecisions.org/products/videos/
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MARY'S CHOICE
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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
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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
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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
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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
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JULIE SPEAKS FOR MARY
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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
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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)
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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
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RISKS
• Infections• Bleeding• Tube leaking• Diarrhea, cramping• Nausea and vomiting
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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
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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
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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
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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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REFERENCES
1. Cervo FA, Bryan L, Farber S. To PEG or not to PEG: A review of evidence for placing feeding tubes in advanced dementia and the decision-making process. Geriatrics. 2006;61(6):30-35.
2. Coalition for Compassionate Care of California http://coalitionccc.org/3. Daya MR, Schmicker RH, Zive DM, et al. Out-of-hospital cardiac arrest survival
improving over time: Results from the resuscitation outcomes consortium (ROC). Resuscitation. 2015. doi: S0300-9572(15)00063-5 [pii].
4. Ebell MH, Jang W, Shen Y, Geocadin RG, Get With the Guidelines-Resuscitation Investigators. Development and validation of the good outcome following attempted resuscitation (GO-FAR) score to predict neurologically intact survival after in-hospital cardiopulmonary resuscitation. JAMA Intern Med. 2013;173(20):1872-1878. doi: 10.1001/jamainternmed.2013.10037 [doi].
5. El-Jawahri A, Mitchell SL, Paasche-Orlow MK, et al. A randomized controlled trial of a CPR and intubation video decision support tool for hospitalized patients. J Gen Intern Med. 2015. doi: 10.1007/s11606-015-3200-2 [doi].
6. Girotra S, Nallamothu BK, Spertus JA, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367(20):1912-1920. doi: 10.1056/NEJMoa1109148 [doi].
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QUESTIONS?