Facts & myths about end-of-life care

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

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.

Liza Manalo, MD

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…

Liza Manalo, MD

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.

Liza Manalo, MD

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.


Liza Manalo, MD

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.

Liza Manalo, MD

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.

Liza Manalo, MD

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.


Liza Manalo, MD

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


Liza Manalo, MD

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.

Liza Manalo, MD

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.

Liza Manalo, MD

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.

Liza Manalo, MD

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.


Liza Manalo, MD

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.

Liza Manalo, MD

 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.

Liza Manalo, MD

 Be careful to avoid the rationale that says,
“death is the treatment!”
 Symptom treatment alleviates symptoms; it
does not intentionally cause death.


Liza Manalo, MD

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.


Liza Manalo, MD

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).


Liza Manalo, MD

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

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

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

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

Liza Manalo, MD

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


Liza Manalo, MD

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

Liza Manalo, MD

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


Liza Manalo, MD

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.


Liza Manalo, MD

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.


Liza Manalo, MD

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.

Liza Manalo, MD

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.

Liza Manalo, MD

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.

Liza Manalo, MD

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.


Liza Manalo, MD

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

Liza Manalo, MD

“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

Liza Manalo, MD

Facts & myths about end-of-life care

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Andere mochten auch

Andere mochten auch (6)

Ähnlich wie Facts & myths about end-of-life care

Ähnlich wie Facts & myths about end-of-life care (20)

Mehr von Dr. Liza Manalo, MSc.

Mehr von Dr. Liza Manalo, MSc. (20)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

Facts & myths about end-of-life care