Oct 25, 2016

Ethics of End-of Life Choices Part 2

Barb Green, Parish Nurse

Milton, WI

Last month I wrote about End of Life issues surrounding CPR and feeding tubes. This article touches on other medical issues.

 

Ventilator

When someone needs help with breathing or suffers respiratory arrest, the doctor may suggest using a ventilator (breathing machine that forces the lungs to work). A tube attached to the ventilator is put down the throat into the trachea (windpipe). Sedation may be necessary as this can be an uncomfortable procedure. People on ventilators cannot communicate and may experience anxiety and fear of not being able to breathe or shortness of breath. A person with chronic lung disease, heart failure, or neurological disease may never be weaned off. A DNR order will prevent placing a ventilator but not prevent other treatments. Alternatives to a ventilator are oxygen, pressurized face mask, special vest, and medications. If a tracheotomy needs to be performed, that tube is attached to the respirator. Risks of a trach include: collapsed lung, plugged trach tube, and bleeding.

Turning off the ventilator does not mean that the patient will die right away. The death is not from withdrawing the machine but the underlying health condition. It is allowing natural death to happen that would have occurred earlier had the machine never been turned on. When the decision to turn it off is made, if the patient has an ICD (implantable cardioverter defibrillator) it needs to be turned off. A pacemaker can stay on as it will not keep a dying person alive.

Hospitalization

Should a person be admitted to the hospital at the end of their life? For some, hospitalization may cause increased anxiety as they get used to new caregivers and new routines (especially for dementia patients). Hospitalization may increase the possibility of contracting an infection. There is a possibility that restraints or sedation may be used especially for dementia patients. Aggressive treatment of their condition may occur along with the possibility of diagnostic testing because equipment is available even if the patient does not want further treatment.

Alternatives to hospitalization include treatment at home with antibiotics or increased pain control. The family can have a “Do Not Hospitalize” order written.

Dialysis

If the patient has acute kidney failure, dialysis may keep him alive until the kidneys can recover. Those with chronic failure can be kept alive for several years before dying from heart disease or infection. On dialysis days the patient will feel wiped out. If the decision is made to stop dialysis the death is peaceful.

Antibiotics and Pain Control

Antibiotics can be given orally with few side effects. They should not be withheld unless that is the patient’s desire. Most often they will be given to cure pneumonia or another infection and the person will feel better.

Depression, spiritual distress, broken family relationships, and lack of sleep can worsen pain. Drugs help, but so do alternatives such as spiritual counsel from clergy, family or friends, meditation, music, prayer, hypnosis, and massage. Pain pills should be taken as prescribed even if they make the patient drowsy. For those who have no history of addiction, these pills are not addictive. As pain increases, the medication may be increased but it is done slowly and does not cause death. Palliative sedation may be requested in the last few hours. Albert Schweitzer wrote: “We must all die. But if I can save him from days of torture, that is what I feel is my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself.”

When discussing end of life decisions, if the answers point to withdrawing or withholding treatment, the hard question becomes for both patient and family, “Can I let go and just let be?” Being able to say yes can be helpful to everyone.