End of life decisions

If you are seriously ill or in the hospital, you may be asked to make many decisions. Some decisions, such as whether or not to accept artificial life support, are very difficult and require careful consideration. The following are some commonly asked questions about artificial life support and other life-sustaining measures.

Frequently Asked Questions
What is CPR?
What are the benefits of CPR?
What are some risks of CPR?
What is artificial life support?
What if I don't want CPR or artificial life support?
What is an advance directive or POLST?
How can I be sure my wishes are followed?
What if I have to make a decision for my loved one?
What if I change my mind?

What is CPR?
Cardiopulmonary resuscitation (CPR) is an all-out effort to save a life by interrupting the natural process of dying. CPR works to restart the heart and lungs when they suddenly stop. Electric shock to the heart, hands pumping on the chest, a tube in the windpipe, and breathing on a machine are common things that happen during CPR. Powerful drugs may also be used to stimulate the heart.

What are the benefits of CPR?
When CPR works, it usually helps immediately to prevent death. A healthy patient whose heart and lungs suddenly stop working may benefit from CPR. In some cases, CPR alone may not solve the problem. When that happens, the patient may need artificial life support for breathing and blood pressure for some time.

What are some risks of CPR?
CPR does not always work. Patients who receive CPR in the hospital may die because they are very sick before their heart and lungs stop working. CPR does present some risks, including broken ribs, brain damage or damage to the windpipe. If artificial life support is needed, it can be uncomfortable for the patient, and it may interfere with talking. A patient who receives CPR may not get well again. The patient may have poor health to begin with, and may be close to natural death. If CPR is started too late, the patient may suffer permanent mental and physical handicaps. If this happens, it may be hard to decide how long to continue artificial life support.

What is artificial life support?
Artificial life support can be as simple as giving nourishment or fluid through a tube. It can be as complex as giving powerful drugs and using machines to artificially keep the heart and lungs working. Artificial life support can interfere with the natural process of dying. Tubes and machines can deprive patients of dignity, comfort and privacy. Life support can also prolong the moment of death. When this happens, life support can be a burden.

What if I don't want CPR or artificial life support?
Many people whose health is failing ask not to be given CPR. Deciding against CPR or life support does not mean all medical care stops. The level of support that a patient chooses to receive is an individual decision. No matter what decision is made, the patient will receive personal nursing and medical care to meet his or her specific needs.

What is an advance directive or POLST?
AnĀ advance directive helps your family and doctor know what treatments you want if you are unable to speak for yourself. Most advance directives say whether you want life support or artificial feeding. Once you sign an advance directive, you and your doctor should each keep a copy of it. Physician Orders For Life-Sustaining Treatment (POLST) is another form that helps hospitals, nursing homes and ambulance teams follow a patient's wishes. Your doctor or nurse practitioner will fill out and sign this form after talking to you about specific treatments, especially those relating to CPR and artificial life support.

How can I be sure my wishes are followed?
After discussing the options with you, your doctor will write specific instructions regarding CPR, life support and response to emergencies. Although the level of support and emergency response is based on the overall treatment goal, you always have the right to refuse any treatment.

The three levels of support are:
  • Total support/full emergency intervention (including CPR)
    • If this order is written, you probably have a completely curable illness. You and your doctor have agreed that the goal of your hospital stay is to return you to your previous health. If your heart weakens or stops completely, you may receive chest compressions (CPR), electric shocks and powerful drugs to stimulate the heart. If your breathing stops or becomes labored, a tube may be put in your throat, enabling you to receive artificial life support on a breathing machine. Although these treatments may cause pain or other discomfort, most people want this type of treatment as long as there is a good chance of complete recovery.
  • Intermediate support/limited emergency interventions (without CPR)
    • If this order is written, you may have an illness that is only partially curable. You and your doctor have decided to try less invasive treatments. If your heartbeat weakens or becomes irregular, you could receive drugs or even electric shock to regulate your heartbeat. If you have trouble breathing, you could receive oxygen, suctioning of the windpipe or artificial breathing support through a tight-fitting mask. Sometimes these treatments cause pain or other discomfort. If your heart or breathing completely stops, this is a sign that the dying process has started. If that happens, chest compressions (CPR) will not be used, and a breathing tube will not be put down your throat. Drugs will be given as needed for your comfort. The doctors and nurses will do everything possible to support you and your family.
  • Comfort support/allow natural death
    • If this order is written, your illness has probably progressed to the point where it cannot be cured. You and your doctor have decided that the main goal of your care is comfort. Nurses will treat any pain or discomfort you may have. Oxygen will be provided if it is needed to help you breathe. Food and/or water will be offered. If your heart or lungs are failing, you will not receive artificial life support. If you are close to death, your pain or discomfort will be treated, and you will be allowed to die naturally and with dignity.
What if I have to make a decision for my loved one?
Hopefully you have had a chance to talk to your loved one about his or her wishes. Use what they said to you directly or in an advance directive. If you have not talked about these things, you may know the person well enough to know what he or she would want. The most important thing is to base decisions on what your loved one would want rather than on your own feelings and ideas. The health care team can help you think through difficult decisions.

What if I change my mind?
A decision about CPR or life support may be changed at any time and should be reviewed whenever there is a change in medical condition. If a change is necessary, your doctor will rewrite the order for response to emergencies.