Difficult Health Care Decisions
Life-sustaining Treatments and their Consequences
This information describes some of the commonly used life-sustaining treatments that are defined as those which, if discontinued or withheld, would with reasonable medical judgement, result in death within a relatively short time, and the potential complications and ethical issues associated with them.
We encourage you to consider this information and discuss any concerns you may have with your physician.
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Cardiopulmonary Resuscitation (CPR)
If the heart and lungs stop working, brain damage and death may occur within minutes. CPR is an emergency procedure that helps move blood through the blood vessels and air through the lungs when the heart stops beating.
Blood flow is usually achieved by chest compression that squeezes the heart, thus producing some blood flow, or by shocking the heart back to normal rhythm with electrical paddles (called a defibrillator).
Movement of air into the lungs is initiated by mouth-to-mouth breathing or through a tube that is placed in the trachea (windpipe).
Problems that can occur when CPR is administered include pain caused by chest compression, electrical shock or by placement of the breathing tube in the throat; and the possibility of incomplete recovery after CPR, resulting in brain, kidney or other organ damage particularly in frail individuals.
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Artificial Ventilation
The body (including the brain) cannot receive the oxygen required to function if the lungs do not work properly. Lung function can be improved through the use of medication and physical measures that help to clear the lungs.
Sometimes, further interventions are needed. Artificial ventilation involves placement of a tube in the trachea (windpipe). The tube is then connected to a machine that helps force oxygen into the lungs to sustain life.
Problems that can occur with artificial ventilation: include discomfort and medical complications caused by the tube; and prolonged or permanent dependence on artificial ventilation to sustain life due to failure of the lungs to function on their own.
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Dialysis
When the kidneys do not function properly, the body cannot remove waste chemicals and water. When kidney function decreases to about 10 percent of normal, it is not possible to sustain life, and dialysis is required. This procedure involves circulating blood from the patient to a dialysis machine that removes the wastes and excess waters, and then returns the blood to the body. When kidney failure has occurred rapidly, and especially when the kidneys were normal previously, the patient usually recovers.
Preparing the patient for dialysis requires placement of tubes in blood vessels and is not very painful. Treatments are not very painful, though occasional weakness, nausea and muscle cramps occur.
There is a slight risk of hepatitis and occasionally serious infection occurs. If the kidneys fail to recover, long-term dialysis is needed. Details on long-term dialysis are available in separate brochures.
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Pacemakers
A healthy heart sparks itself with an electrical impulse in order to beat regularly. Sometimes this self-sparking ability ceases, preventing the heart from pumping blood.
In emergency cases, paddles (called a defibrillator) are used to provide an external shock to the heart to get it beating properly. Some people need a pacemaker, a device that provides the necessary electrical spark. Like most treatments, the need may be temporary or permanent.
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Artificial Methods of Nutrition
Without food and fluid, a person cannot survive. When a patient cannot eat or drink, fluid is usually provided through an intravenous line placed into the veins.
If a patient cannot swallow, a tube can be placed into his/her digestive system to provide nutrition. When the tube is needed temporarily, a plastic tube is usually used, which passes through the nose into the stomach. For longer periods of time (or permanently), a surgical procedure is may be performed in which a rubber tube is inserted into the stomach through the belly. A thorough discussion should take place among doctors, family and caregivers and the patient (if possible) before this tube is placed.
Sometimes there is a serious problem with the digestive system, and food substitutes need to be provided through the veins. This is known as total parenteral nutrition (TPN).
The risks associated with TPN are generally less than other medical treatments, but may be substantial, including infection of the blood and collapse of the lung due to placement of the intravenous line. Artificial feeding and fluids may be withheld when appropriate, usually in cases when chances for recovery to a meaningful life are minimal and would prolong suffering.
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Medications
Medications can help improve the quality of life and, in some cases, are needed to preserve life itself. Every medication has both expected benefits and possible harmful side effects.
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Bioethical Issues
When chances for recovery are minimal, you may need to decide whether or not to use life sustaining measures. It is often a good idea to discuss with your physician the expected benefits, possible side effects, and the chances that these measures will be successful, both in terms of survival and quality of life.
Your Decisions
This information can serve as a starting point for further discussions with your physician, nurse, and family members.
A patient may accept or refuse life sustaining measures.
However, sometimes medical conditions arise that can make it impossible for you to voice your preference. It is extremely valuable for you to talk to your physician about your wishes regarding life sustaining measures at a time when you can make good decisions and clearly express your preferences.
In California there is a document available to help you state your wishes with regard to treatment (or non-treatment) if you are no longer able to speak for yourself.
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The Advance Health Care Directive
An Advance Health Care Directive carries full legal status to state your wishes.
Copies of the Advance Health Care Directive are available free through the hospital Admitting Office or Senior Focus at 800-654-9966.
Make your wishes clear.
While it is difficult for anyone to consider the possibility of becoming seriously ill or dying, we recommend that you think about the issues raised in this booklet. Tell your physician and family your wishes for treatment before you are either unable to express your wishes directly or if chances of recovery are minimal.
To make your wishes clear and easy to carry out the document previously described and have it filed in your medical records.
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Bioethics Committee
Mills-Peninsula's Bioethics Committee is available for consultation. The committee assists in developing hospital policies regarding ethics.
Members of this committee include nurses, doctors, clinical social services, chaplain, patient representative and an ethicist.
You may contact a member of the Bioethics Committee either through your physician or nurse, or directly by calling the Medical Staff Office at 650-696-5660.