Ethics of End-of Life Choices

Barb Green, Parish Nurse

Milton, WI

 

Making wise end-of-life decisions for someone who has designated you as his health care power of attorney is a difficult thing to do even when you know that person’s values and wishes. Others, besides you, may have opinions to consider. What if the dying person has trouble breathing and the doctor says a ventilator might be useful? What if one family member wants to “do everything” to keep the person alive? “Everything” means all measures that might keep the vital organs working: CPR, ventilator, dialysis, feeding tube etc. Sometimes these are temporary measures that allow the body to heal itself and begin to work normally again. Sometimes they just end up prolonging the person’s life indefinitely.

Here are pros and cons of some of these issues:

CPR

When the heart stops beating CPR, a defibrillator, and/or medications can all be used.

  • CPR originally was intended for accidental deaths such as drowning or for relatively healthy people. Early guidelines suggest that it should not be used in irreversible terminal conditions where death is not unexpected. Resuscitation in these circumstances may represent a violation of a person’s right to die with dignity.
  • The survival rates are not good. In one study only 15.2% survived to be discharged from the hospital. For a person who has more than one or two medical problems, the rate drops to 2%. For those who depend on others for care or live in a long term care facility, and those who have a terminal disease, the rate is 0-2%.
  • Problems include broken ribs, punctured lung or spleen due to the force needed, and brain damage if the person has been without oxygen for a period of time. Prolonged survival on machines with a severe brain injury is not what most want. It severely reduces the possibility of a peaceful death.
  • CPR is a standard order when a person enters a hospital or nursing home unless there is a doctor’s order restricting its use. This can be called no code, no CPR, DNR, DNAR (do not attempt resuscitation) or AND (allow natural death).

Artificial Hydration and Nutrition

A feeding tube can allow stroke victims nutrition until swallowing returns. Unless a conscious choice has been made not to allow a feeding tube, standard medical practice may include starting one for any patient who can no longer take in enough food or water by mouth.

Many argue that food and water are basic forms of care that should not be denied and the intent of withholding a tube is to allow death. Others feel that we are not obligated to preserve our life at all costs and that a feeding tube becomes morally optional when the benefits would not be sufficient for the patient or would cause clinical burdens or physical discomfort. To withhold a tube is to allow death from the underlying condition and is not introducing something that kills the patient. Pain can still be controlled. Dehydration in the end stage of a terminal illness is a natural and compassionate way to die.

Benefits of not using artificial hydration in a dying patient include less fluid in the lungs so breathing is easier; less fluid in the throat so less need for suctioning; less urination so less need to move patient for changing the bed and less chance of bedsores; less fluid retained in the body in general. Forcing fluids in a body that is shutting down can make for uncomfortable fluid buildup. There is a natural release of pain relieving chemicals as the body dehydrates which suppresses appetite and causes sense of well-being.

All during treatments and decisions, the family and the physician need to weigh the benefits of treatment with quality of life. Our first reaction when we must make a choice is to do everything we can to preserve life. Knowing all the facts may help us realize that unwise choices may actually make a loved one suffer more than if we let him die a natural death. Letting go is a hard choice but may be the best for everyone concerned.

Next month: Ethics of Choices, Part 2

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