1. KRISTEN CHASTEEN MD PALLIATIVE MEDICINE, HENRY FORD HOSPITAL NAVIGATING DECISIONS ABOUT LIFE-SUSTAINING TREATMENTS

2. OBJECTIVES Recognize that eliciting a patient’s values is the first step in making decisions about life sustaining treatments Describe an overview of common life-sustaining medical treatments CPR Mechanical ventilation Artificial nutrition and hydration Describe some of the risks and benefits of life- sustaining therapies

3. FACTORS INFLUENCING DECISIONS Values Faith Emotions Medical facts Decisions about life- sustaining treatments

4. RISKS AND BENEFITS

5. MARY 80 year-old woman History of diabetes, mild kidney disease and now has a new diagnosis of early Alzheimer’s dementia Hospitalized once in the past year for a serious bladder infection Lives alone in an apartment since her husband died 8 years ago Daughter, Julie, lives nearby and visits several times a week Faith is important to her and she is an active member of a Presbyterian church

6. VALUES Independence Recognize and communicate with family, friends Strong faith in God and belief in miracles also influences decision making

7. CARDIOPULMONARY RESUSCITATION (CPR) When Mary was in the hospital last time, the doctor asked her about her code status Full code – in the event of cardiac arrest, CPR should be attempted DNR/DNAR/Do not resuscitate - in the event of cardiac arrest, CPR should not be attempted

8. CARDIAC ARREST Loss of heart function, breathing, and consciousness The heart's electrical system malfunctions and the heart stops pumping blood to the rest of the body Results in death without immediate treatment

9. CARDIOPULMONARY RESUSCITATION (CPR) Pressing hard and fast on the center of the chest to pump blood through the body

10. CARDIOPULMONARY RESUSCITATION (CPR) CPR also involves Pushing oxygen into the lungs by a mask or by inserting a breathing tube Defibrillation Intravenous medications

11. INTUBATION Inserting a breathing tube down the mouth into the windpipe (trachea) and pushing oxygen into the lungs using a machine called a ventilator

12. DEFIBRILLATION Using electric shocks to restart the heart

13. INTRAVENOUS MEDICATION Putting strong medications like epinephrine into the vein to help restart the heart

14. OUTCOMES Cardiac arrest out of the hospital 10% survival to hospital discharge Cardiac arrest in the hospital 20% survival to hospital discharge ½ of survivors will have minimal or no brain damage Patients with lower chance of survival Older, frail, chronic medical illness Live in a nursing facility Kidney or liver problems Widespread (metastatic) cancer

15. BENEFIT Chance of survival to be well enough to leave the hospital Chance of returning to previous health state and level of functioning

16. RISKS High chance of dying in an ambulance, emergency room, or intensive care unit (ICU) Interferes with family presence at the time of death Patient pain and suffering during CPR Patient pain and suffering from additional procedures during an ICU stay after the arrest Prolonged dying process may be burdensome for family Chance of survival with brain impairment or reduced level of functioning

17. CPR http://www.acpdecisions.org/products/videos/

18. MARY'S CHOICE

19. MARY Mary lives for another 5 years and progresses to advanced dementia Unable to get out of bed No longer recognizes friends and family and barely speaks Lives in a skilled nursing facility Eating very little Transferred to the hospital after developing pneumonia

20. VENTILATOR A tube is inserted down the mouth into the windpipe (trachea) and a machine is used to push oxygen into the lungs Not able to eat or talk Often given sedating medications to ease discomfort Tracheostomy: If a ventilator is used long-term, a surgery may be performed to make a hole in the windpipe (trachea) and insert a tube to connect to the ventilator

21. BENEFITS Supports breathing while an acute illness (like infection) is treated May allow full recovery to previous health state Some people with brain, spinal cord, or nerve diseases may have breathing problems many years before the end of their lives and a ventilator may help them live longer and enjoy additional years of satisfying life

22. RISKS Someone with advanced incurable illness is much less likely to survive or return to their previous health state Pain from the breathing tube and other procedures in the ICU Worsening confusion Restraints

23. JULIE SPEAKS FOR MARY

24. MARY Admitted to the hospital Given IV antibiotics to treat her lung infection Given small doses of morphine to ease her discomfort from difficulty breathing Recovers from her infection, but not able to eat A swallowing test shows that when she swallows, food goes into her lungs Julie asks about a feeding tube

25. TUBE FEEDING When a person cannot swallow or is too sick to eat, a feeding tube delivers liquid nutrition formula directly into the stomach A temporary tube can be placed through the nose into the stomach (NG tube) A long-term tube can be placed by a surgery through the skin into the stomach or intestines (PEG tube)

26. BENEFITS For people with a temporary serious illness, a feeding tube can allow adequate nutrition until they are able to recover and eat on their own For people with a blockage in their throat or esophagus, a feeding tube may bypass the blockage Some people with brain or nerve diseases may lose the ability to swallow many years before the end of their lives and a feeding tube may help them live longer

27. RISKS Infections Bleeding Tube leaking Diarrhea, cramping Nausea and vomiting

28. FOR PEOPLE WITH ADVANCED DEMENTIA OR AT THE END OF LIFE Can cause agitation and cause restraints to be needed to prevent pulling at the tube Do not prevent aspiration of saliva into the lungs or recurrent lung infections Do not extend life Can cause swelling in the body, diarrhea, stomach pain, and fluid in the lungs

29. ARTIFICIAL HYDRATION Medical treatment that provides water and salt (saline) to someone who is too sick to drink enough on their own or who has problems swallowing Given by an IV in a vein or under the skin

30. ARTIFICIAL HYDRATION AT THE END OF LIFE People stop drinking as part of the natural dying process People who are very near the end of life usually do not feel thirst Can cause swelling, fluid build-up in the lungs and back of the throat, nausea or vomiting

31. MARY Enrolls in hospice care and returns to the nursing home Sponge swabs used to prevent dry mouth and lotion to prevent dry skin Small doses of morphine used as needed to continue to allow her to breath comfortably Dies with Julie at her bedside one week later

32. REFERENCES 1.Cervo FA, Bryan L, Farber S. To PEG or not to PEG: A review of evidence for placing feeding tubes in advanced dementia and the decision-making process. Geriatrics. 2006;61(6):30-35. 2.Coalition for Compassionate Care of California http://coalitionccc.org/ 3.Daya MR, Schmicker RH, Zive DM, et al. Out-of-hospital cardiac arrest survival improving over time: Results from the resuscitation outcomes consortium (ROC). Resuscitation. 2015. doi: S0300-9572(15)00063-5 [pii]. 4.Ebell MH, Jang W, Shen Y, Geocadin RG, Get With the Guidelines-Resuscitation Investigators. Development and validation of the good outcome following attempted resuscitation (GO-FAR) score to predict neurologically intact survival after in-hospital cardiopulmonary resuscitation. JAMA Intern Med. 2013;173(20):1872-1878. doi: 10.1001/jamainternmed.2013.10037 [doi]. 5.El-Jawahri A, Mitchell SL, Paasche-Orlow MK, et al. A randomized controlled trial of a CPR and intubation video decision support tool for hospitalized patients. J Gen Intern Med. 2015. doi: 10.1007/s11606-015-3200-2 [doi]. 6.Girotra S, Nallamothu BK, Spertus JA, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367(20):1912-1920. doi: 10.1056/NEJMoa1109148 [doi].

33. QUESTIONS?