Withholding.withdrawing

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Withholding.withdrawing

  1. 1. Withholding/withdrawing life-sustaining therapies<br />Suzana Makowski, MD MMM FACP<br />
  2. 2. The<br />EPEC-O<br />TM<br />Education in Palliative and End-of-life Care - Oncology<br />Project<br />The EPEC™-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.<br />
  3. 3. Overall message<br />Withholding or withdrawing life-sustaining therapies is sometimes warranted, is ethical and legal in many circumstances.<br />
  4. 4. Examples of life-sustaining therapies<br />Resuscitation<br />Intubation/mechanical ventillation<br />Blood transfusions<br />Dialysis<br />AICD<br />Antibiotics<br />Artificial hydration/nutrition<br />Hospitalization/ICU admissions<br />Surgery<br />Diagnostic tests<br />
  5. 5. Let’s talk about food<br />
  6. 6. Enteral Nutrition<br />NG, PEG, Jtube<br />Head & neck cancer, <br />Neurologic injury<br />Temporary loss of ability to eat.<br />
  7. 7. Enteral Nutrition & Survival<br />No effect on:<br />Aspiration risk<br />Pneumonia risk<br />Symptoms.<br />Associated with increased mortality in patients with dementia, etc. <br />
  8. 8. Parenteral nutrition<br />Venous access<br />Beneficial with: long-term gi toxicity, short gut syndrome, ovarian carcinomatosis.<br />Not beneficial in: long-term feeding for cachexia/anorexia.<br />
  9. 9. Effects of nutrition on survival & response rates<br />
  10. 10. Parenteral hydration<br />IV or SQ<br />Does not relieve dry mouth<br />
  11. 11. Common Concerns<br />Legally required to do everything?<br />Is withholding or withdrawing care euthanasia?<br />Are you (or the family) killing the patient by withholding or withdrawing nutrition, fluid, or life-sustaining treatment?<br />
  12. 12. Steps to discuss withholding/withdrawing artificial nutrition/hydration<br />S – set-up, background<br />P – Preparation<br />I – Inquiry: what are the goals? What is the understanding? What cultural beliefs?<br />K – Knowledge: listen and share. Address misperceptions. (Not alleviate: dry mouth, decrease intake, fatigue/energy, starvation, urine output. Side effects: fluid overload, breathlessness, nausea/vomiting.)<br />E – Emotions: wait. Acknowledge. (starvation, giving up, suffering, “not doing something”)<br />S – Summarize/strategize<br />
  13. 13. Cases<br />
  14. 14. “We want to do what’s best, and what she wanted us to do…”<br />CS is an 82 yo woman found unresponsive at home. Found to have large hemorrhagic stroke MCA, with only brainstem function remaining. PMH: HTN, high cholesterol.<br />Exam: Respirations shallow, rapid. HR fast. Unresponsive.<br />Brought “comfort one” form from refrigerator.<br />Niece is HCP. Agrees DNR/DNI no ICU. What is comfort care? Pt hasn’t eating in 3 days: doesn’t she need IVFluids, blood tests, oxygen tests?<br />
  15. 15. “I don’t want her to starve”<br />89 yo patient with advanced Alzheimer’s dementia (speaks only a few intelligible words, dependent on all ADLs) admitted with dyspnea, cough, mental status change found to have aspiration pneumonia. Found to have aspiration pneumonia. Failed swallow evaluation.<br />Daughter/son knows patient doesn’t want pt to starve, but is concerned that pt can’t swallow. Additionally, nursing home might require feeding tube for readmission.<br />
  16. 16. Thank you<br />

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