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MYTHS & FACTS
About End-of-Life Choices:
CPR & DNR
Palliative Sedation
LIZA C. MANALO, MD, MSc.
PALLIATIVE CARE
Philippine...
MYTH: DNR equals “Do Not
Care.”
 FACT: A DNR order means absolutely
everything will be done up to the point that
the pati...
MYTH: CPR is usually successful.
 FACT: CPR frequently can save a person's
life, particularly in the case of some kinds o...
MYTH: CPR is usually successful.
 FACT: …Another possibility is that CPR may
be only partially successful. If the heartbe...
MYTH: CPR can’t hurt.
 FACT: Pushing the center of the chest down
about one and one-half inches, 100 times a
minute for s...
MYTH: “Doing everything” means
we need to do CPR.
 FACT: “Doing everything,” means doing
everything that is right medical...
MYTH: DNR means that we are
abandoning the patient or not
providing him or her with every
opportunity of life.
 FACT: The...
Withholding, Withdrawing
Life-Sustaining Treatment
Emanuel LL, von Gunten C J, Ferris FD

Education for Physicians on End-...
ANY LIFE-SUSTAINING THERAPY…
Resuscitation (CPR)
Elective
intubation, mechanic
al ventilation
Surgery
Dialysis, Hemofi...
Are physicians legally required to provide all
life-sustaining measures possible?

 No. To the contrary, patients have a ...
Is withdrawal or withholding of treatment
equivalent to euthanasia?
 No. There is a strong general consensus that
withdra...
Are you killing the patient when
you remove the ventilator and
treat the pain?
 If the intent is to secure comfort, not d...
Are you killing the patient when
you remove the ventilator and
treat the pain?
 Usually, actions intended to provide comf...
Can the treatment of symptoms
constitute euthanasia?
 For patients who have been using opioids for
pain, it is in fact ve...
Can the treatment of symptoms
constitute euthanasia?
 Patients tend to sleep off the effect if they
get too much medicati...
Can the treatment of symptoms
constitute euthanasia?
 Be careful to avoid the rationale that says,
“death is the treatmen...
Is it illegal to prescribe large doses of
opioids to relieve symptoms of pain,
breathlessness, or other symptoms?
 Even v...
Is palliative or terminal sedation equivalent to
euthanasia?
 No. Palliative or terminal sedation of those
imminently dyi...
Palliative Sedation vs. Euthanasia

 In terminal or palliative sedation of those
imminently dying:
The intention is to r...
Palliative Sedation
 In palliative care, mild sedation may be used
therapeutically but in this situation it does not
adve...
What does the medical team do when a
competent patient has previously refused
treatment, but the surrogate decision-maker
...
HOPE
Hope lies not only in an expectation of cure or even of the
remission of present distress. For dying patients, the ho...
HOPE
There are those who will find hope in faith and their belief in an
afterlife; some will look forward to the moment a ...
The problem with doctors
 Doctors are no more immune to a fear of death
than the rest of us, it seems—especially when the...
Competent Care for the Dying
 In the real world in which physicians care for dying
patients, withdrawing treatment and ag...
SUMMARY
 Competent patients have the right to make
decisions about their own treatment, the right to
accept or refuse med...
SUMMARY
 Withholding or withdrawing life-sustaining
therapies is ethical and medically appropriate in
these circumstances...
SUMMARY
 Terminally-ill patients with decision-making capacity
can opt to forego any extraordinary medical
intervention a...
CONCLUSION
 Facilitating decision making and
implementing decisions about life-sustaining
treatments are essential skills...
CONCLUSION
 No one doctor can claim to have all the
answers and patients and their families
appreciate truthfulness and s...
CONCLUSION
 There is a need to individualize care option
discussions to illness status, and patient and
family preference...
FURTHER READING
 End-of-Life Decisions about Withholding or
Withdrawing Therapy: Medical, Ethical, and
Religio-Cultural C...
“We have to ask ourselves whether medicine is to remain a
humanitarian and respected profession, or a new but depersonaliz...
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Facts & myths about end-of-life care

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Facts & myths about end-of-life care, CPR, DNR, and palliative sedation

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Transcript of "Facts & myths about end-of-life care"

  1. 1. MYTHS & FACTS About End-of-Life Choices: CPR & DNR Palliative Sedation LIZA C. MANALO, MD, MSc. PALLIATIVE CARE Philippines Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  2. 2. 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
  3. 3. 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… Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  4. 4. 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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  5. 5. 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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  6. 6. 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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  7. 7. 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 or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  8. 8. Withholding, Withdrawing Life-Sustaining Treatment Emanuel 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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  9. 9. ANY LIFE-SUSTAINING THERAPY… Resuscitation (CPR) Elective intubation, mechanic al ventilation Surgery Dialysis, Hemofiltrati on Blood transfusions, blood products …aimed at maintaining Diagnostic tests Artificial nutrition, (parenteral or enteral) or hydration (IVF) Antibiotics Vasopressors Future hospital, ICU admissions organ function that only prolong death may be withdrawn or withheld Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  10. 10. 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 lifesustaining 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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  11. 11. 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. -Emanuel LL, von Gunten C J, Ferris. (1999). Education for Physicians on End-of-Life Care Trainer's Guide. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  12. 12. 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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  13. 13. Are you killing the patient when you remove the ventilator and treat the pain?  Usually, actions intended to provide comfort and freedom from unwanted intervention result in a slower progression to death than do actions intended to euthanize. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  14. 14. 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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  15. 15. Can the treatment of symptoms constitute euthanasia?  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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  16. 16. Can the treatment of symptoms constitute euthanasia?  Be careful to avoid the rationale that says, “death is the treatment!”  Symptom treatment alleviates symptoms; it does not intentionally cause death. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  17. 17. 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. -Emanuel LL, von Gunten C J, Ferris. (1999). Education for Physicians on End-of-Life Care Trainer's Guide. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  18. 18. Is palliative or terminal sedation equivalent to euthanasia?  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). Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  19. 19. 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 drug The successful outcome is immediate death Materstvedt et al, Palliative Medicine 2003 Liza Manalo, MD
  20. 20. 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
  21. 21. 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 decisionmaker 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. Liza Manalo, MD
  22. 22. HOPE Hope 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 Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  23. 23. HOPE There 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 Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  24. 24. 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 Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  25. 25. 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 Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  26. 26. 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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  27. 27. SUMMARY  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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  28. 28. SUMMARY  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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  29. 29. 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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  30. 30. 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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  31. 31. 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. Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  32. 32. FURTHER READING  End-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-lifedecisions-about-withholding-or-withdrawingtherapy-medical-article-a3582 Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
  33. 33. “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.” “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 Withholding or Withdrawing Life Sustaining Treatment Liza Manalo, MD
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