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Letting Go: Facing End-of-Life Treatment Decisions |
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Letting Go For the families, these decisions are almost wholly about coming to the point of letting go. My observation has been that families of those suffering from Alzheimer's are, on the whole, able to approach these issues with a great deal of grace. I feel one of the reasons is that these families have been suffering losses for years. The grief work has already begun. Thoughts of letting go of someone, though never easy, come as a matter of course for these families. The idea of letting go is so central to these end-of-life decisions. Often the withholding of something like CPR is the only reasonable medical course, but caregivers sometimes have a hard time letting go and refuse to consent to an order to withhold such aggressive treatment. I have found over the years that families occasionally choose a more aggressive course of treatment to take care of their own emotions rather than doing what is in the best interest of the patient. Though the greater part of these decisions are emotional and spiritual, there are, of course, medical considerations. CPR Let's talk about CPR for a moment. Cardiopulmonary Resuscitation was developed in the 1970's to help rescue victims of sudden death like a heart attack or those who drowned. Originally it was never intended for patients in a hospital or nursing home whose death was not unexpected. Yet today if a physician has not written a "do not resuscitate" (DNR) order, CPR is routinely used on every heart that stops whether in a hospital, a nursing home or out in the community. The truth is that CPR is ineffective in providing long term survival to frail patients like those typically suffering from dementia. Less than 2% of these patients even survive the procedure. Those who do survive are in worse condition than before their heart stopped and will possibly spend their last days, weeks or months in a hospital Intensive Care Unit (ICU). Because of the poor prognosis of CPR with frail, demented patients, I feel it is most appropriate to have a DNR order. Having such an order is not giving up on life. It is giving up on the idea that CPR can provide long-term survival. One can still live life as fully as possible even while refusing a treatment which offers no hope of saving a life. As with any of these decisions, discuss this with the patient's physician and get his/her recommendation regarding your particular case. Artificial Feeding Tube Another treatment decision that families sometimes face is the use of an artificial feeding tube. Eating difficulties can accompany the later stages of Alzheimer's. Most people see this as a sign of the progression of the disease and therefore it does not have to be treated aggressively with an artificial feeding tube. In a great deal of these cases a feeding tube may only prolong the dying process and make the patient more uncomfortable. A legitimate question would be, "Wouldn't the patient die of dehydration without artificial feeding and wouldn't that be painful?" Yes they probably would die of dehydration. Since the beginning of time people have been dying like this and many do so today. Research and clinical evidence reveals that dying without being artificially hydrated through a feeding tube or an IV is a very compassionate and comfortable way to die. On the other hand, hydrating by a feeding tube or IVs may prolong the dying process and may make it more uncomfortable by filling the body with fluids which can gather in the throat and lungs. Comfort Measures Only/Hospice When a patient reaches the final stage of Alzheimer's, many physicians and families consider providing comfort measures only or enrolling in a hospice program. Dementia's final stage has the following characteristics:
When death is inevitable many choose to provide hospice or comfort measures only. The goal is to provide the patient with a comfortable and dignified death. Only medications and procedures which promote this end are used, like pain medications or oxygen. This approach may include choosing to forgo antibiotics because they may only prolong the dying process and will not cure the underlying problem -- Alzheimer's. The physician will be able to assist you with these medical decisions. Through all these decisions the family will be going through the emotional and spiritual struggle of letting go. Hopefully, you will have a support system of friends, social workers, counselors, a spiritual congregation and clergy to aid you in your journey.
by Reverend Hank Dunn
Last updated: October 5, 1998
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