Whenever a patient progresses to the moment in the course of a disease where the prognosis is no longer positive, naturally they want to do everything they can to ensure that they live for as long as they can, and as comfortably as they can. It’s part of human nature to want to stop death from interrupting our lives and our relationships; unfortunately, it is the one thing that cannot be avoided. However, when one is nearing the end of life, there are certain technologies and treatments that can be employed to extend a life and improve the quality of life in those final months. There are two main schools of thought surrounding end of life treatments and technologies: the method which seeks to extend life for as many moments as possible, without regard to pain and suffering, and palliative care, a method which seeks to find a balance between extending a patient’s life and making their final memories free of unnecessary suffering.
The typical “aggressive” end of life treatments consist of kidney dialysis, chemotherapy, cardiopulmonary resuscitation and electronic defibrillation, mechanical ventilation and artificial feeding. The first treatment examined herein, kidney dialysis, is hardly a treatment used exclusively in the last year of life. End-stage renal disease (ESRD) is typically the cause of death for patients with kidney failures, but dialysis treatment is meant for patients with Chronic Kidney Disease (CKD). Dialysis is used in patients with CKD to mimic kidney function if there is no hope for a transplant for the failed kidney. Essentially, dialysis is responsible for removing waste and excess water from blood; if dialysis was removed without a kidney transplant, water and waste would accumulate in the blood. Eventually, the amount of waste and toxins in the bloodstream would cause a patient to go into a coma and, following that, pass away. There are two basic dialysis treatments: hemodialysis and peritoneal dialysis. Hemodialysis involves connecting the bloodstream to a machine, which filters and processes the patient’s blood outside of the body in the dialyzer, and the clean blood is then returned to the body. Normally the connection is made by connecting an artery to a vein to create a large enough blood vessel, typically on the upper leg, forearm or neck. Hemodialysis sessions typically take three to four hours, and sessions must be performed two to three times a week.
Peritoneal dialysis, on the other hand, cleans the blood inside of the patient’s body by means of inserting a solution called dialysate into the abdominal area, using the liner of this sac as a filter. In this method, a patient’s blood is filtered while they perform everyday activities, or even while they sleep. For this treatment, a catheter is permanently inserted into the abdominal cavity, and the patient can fill and drain the solution for every session. Typically it takes half an hour to both fill and drain the dialysate, and up to three to four fills and drains, or exchanges, should take place every day.
Another fairly “aggressive” treatment that is typically used towards the end of life in cancer patients is chemotherapy. Chemotherapy is a systematic chemical treatment that targets cancer cells; it is considered highly effective because it is able to attack cells that are separated from the original development of the tumor, creating a better chance for ridding the body of cancerous cells and tumors. Chemotherapy treatments are generally administered through injection into the body, but depending on the treatment regimen, oral pills can also be utilized. While chemotherapy kills cancer cells, it does this by attacking fast-growing cells; therefore, chemotherapy treatments can also attack hair and blood cells, which is why many patients lose their hair when starting chemotherapy treatments. Because chemotherapy drugs can target blood cells, occasionally a side effect of chemotherapy is a reduced white blood cell count, which makes patients more susceptible to infections and illnesses. While, on the whole, chemotherapy seems to work well for cancer patients, there are some cases where the cancer keeps returning or simply cannot be eradicated in the first place. In these cases, it is possible that a patient could receive multiple sessions of chemotherapy treatments. With repeating chemo treatments, at times the focus changes from curing the patient to simply controlling the cancer, and keeping the tumors and cell growth concentrated in one area. The side effects of chemotherapy can be debilitating, therefore careful consideration should be taken before undergoing multiple rounds of chemotherapy. Typical side effects range from anemia, constipation, nausea and vomiting to appetite changes and fatigue. There are some palliative care methods in place to aid with alleviating these symptoms, including sleep, hydration and nutrition schedules as well as stress reduction and physical activity. With very advanced cancer prognoses, it is common for chemotherapy treatment to be focused on improving the quality of life of the patient, rather than controlling or curing the cancer. This falls under the definition of palliative care, though it can still be referred to as chemotherapy since drugs are being applied to the patient in a scheduled regimen. Even during an “ordinary” chemotherapy treatment to try and evict the cancer cells from a body, two drugs can be used at the same time. In fact, it can be preferable to use two drugs coupled together with lesser side effects than to use one very effective drug that also has very aggressive and negative side effects.
As a patient nears the end of life, there are certain technologies which can be employed to extend life, including cardiopulmonary resuscitation (CPR) and electronic defibrillation. In cases where a patient’s heart stops beating as a result of cardiac arrest, CPR is immediately applied as the default response in any hospital setting. However, over the past thirty years, the survival rate of patients receiving CPR in a hospital setting has remained a constant 14-15%. This rate is based on a connection with discharge from the hospital as survival; the remaining 85% of patients receiving CPR in a hospital setting end up passing away at the hospital, without being able to return home or to an extended care facility. Even with this low survival rate, nurses and doctors at any hospital are legally obligated to perform CPR unless the patient has a valid Do Not Resuscitate (DNR) order, regardless of what state the patient is in when they go under cardiac arrest. While CPR, especially with the aid of automated electronic defibrillation, can restore a steady heartbeat to a patient following cardiac arrest, the physical exertion required to make CPR effective can cause significant damage to patients. Many patients that are already hospitalized and receive CPR suffer from prolonged mechanical ventilation, pneumonia and cracked ribs. If normal heartbeat is not restored quickly enough with the aid of an automated electronic defibrillator (AED) and/or CPR, patients can also suffer neurologic damage resulting in reduced functionality. It is said, therefore, that when used without consideration to the patient’s current medical condition, CPR is “capable of prolonging life, sometimes at the cost of deteriorating quality of life.”
One primary issue with cardiopulmonary resuscitation is that there is no clear indication of who should be responsible for deciding whether or not a patient receives CPR. Some claim that it is unethical of doctors to make patients responsible for the condition if they don’t have full knowledge and/or understanding of their medical prognosis, because this could lead patients to make a poorly informed decision. Alternatively, some argue that doctors have a moral obligation to take the patient’s desires into account, and that no medical personnel has the right to decide whether or not a patient is worthy of receiving CPR. Ultimately, the only way for a patient to not be resuscitated by means of CPR is with the presence of a DNR order; otherwise, all patients will be subject to this treatment whether they prefer it or not.
Another technology commonly employed at the end of one’s life is mechanical ventilation. Typically ventilation is used in critically ill patients to aid in the breathing process. The most common means of mechanical ventilation is via non-invasive positive pressure ventilation. In this case, a face mask or nasal mask provides oxygen to the patient in regulated pressure levels, to imitate the respiratory cycle. Most patients in need of mechanical ventilation suffer from respiratory failure or acute respiratory distress syndrome (ARDS). Patients suffering from chronic obstructive pulmonary disease (COPD) also are subject to mechanical ventilation treatments. Mechanical ventilation historically has worked very well for patients that simply need help breathing and have no underlying conditions; however, there are potential risks associated with utilizing mechanical ventilation when other comorbidities (diseases aside from the primary disease of the patient) are at stake. Using mechanical ventilation can frequently cause patients to contract pneumonia, and on rare occasions, ventilation tubes can be accidentally pulled or removed from the patient, causing problems. Therefore, some studies recommend tracheostomy in patients that are critically ill; since these patients will likely be on mechanical ventilation in a hospital setting for the remainder of their lives, implementing tracheostomy leaves less chance for the spread of air-borne diseases. Employing tracheostomy has shown potential to lessen time spent in the ICU (5 days vs. 16 days for ventilated patients) as well as a lower mortality rate (32% vs. 62% for ventilated patients). One component to bear in mind with regards to tracheostomy, however, is that following tracheostomy it will be necessary for the patient to receive artificial feeding as well.
Artificial feeding is the means of nourishing a patient via a tube through the nose which reaches the stomach or a surgically inserted tube through the skin to the stomach wall. Feeding tubes generally deliver water and nutrients to a patient, but may also be used for drug delivery as well. In cases where a patient is physically unable to eat, due to a tracheostomy or other physical disability, artificial feeding is a means for patients to receive the food needed to continue living. However, in cases where a patient does not have an appetite, artificial feeding is viewed by some as “prolonging death” rather than extending life. This is because as the body begins shutting down when it nears the end of life, it no longer needs as many nutrients, so a loss in appetite is considered natural. In fact, artificial feeding could actually cause the patient more pain, as more water in the patient’s system could cause more congestion, making breathing more difficult. The added water could also create pressure buildup around tumors. Many people are under the assumption that without artificial feeding, a patient would starve to death; this is not true. At this stage in life, opting out of artificial feeding would not cause starvation or pain; occasionally dehydration can occur in patients, but it typically presents itself in the form of dry mouth, not in intense thirst.