End of Life
The above picture is from medlineplus.com
Helping patients that are elderly or have terminal illness that are near the end of their life is a sacred duty and calling.
Everything should be done to help to maximize comfort and well being of a patient in their final days here on earth. What is best for the patient at the end of their life? It should be what the patient really wants the most right? Atul Gawande, the author of the book “Being Mortal” addresses this issue beautifully. He focuses on what the patient really wants at the end of their life by asking them what they really want.…. who would have thought? This topic is tip toed around way too much and often not addressed at all.
A do-not-resuscitate (DNR) order is arguably one of the most important decisions in patient care, yet it is an area in which the necessary physician-patient communication is often neglected.1–5Can Fam Physician. 2012 Apr; 58(4): e229–e233.
According to a study in Maryland which has a similar population to that of America in diversity only 1/3 of the population in the state have an advanced directive. Pollack KM, Morhaim D, Williams M. The public’s perspectives on advance directives in Maryland: .
One way to respect the rights of patients in their end of life is to have the discussion about their wishes about what they want most at the end of their life. Have the discussion today with your elderly patients, family members, spouses, and loved ones. Does an elderly patient with terminal cancer that has a prognosis of 6 months to live want to try aggressive chemotherapy, radiation with profound side effects of fatigue, sleepiness, and constant nausea to get 1 more month of life? Or do they want 6 months of life to interact with their family members with a clear mind, not nearly as much nausea/fatigue and a much higher quality of life. Obviously each case is different but this happens sometimes with patients that have a terminal condition. They could even have exponentially less pain with morphine from hospice care if the Dr approves it. Ask the physician realistically how much time you have left or your family member has left. Ask the physician to be realistic and clear.
Sometimes it is best for the physician not to aggressively treat to cure. Sometimes it is better for the physician to treat for comfort. This path can help the finances of the patient/family/Medicare system as well.
In 2008 Medicare paid $50 billion just for doctor and hospital bills during the last two months of patients’ lives. It is estimated that 20 to 30 percent of these medical expenditures may have had no meaningful impact. cbsnews.com 2009
In 2011 Medicare spent 28 percent of their total expenditure, or about $170 billion, on patients’ last six months of life (Pasternak, 6/3).kaiserhealthnews.org
Make sure you have filled out the forms below…
- Advanced Directive / Living Will
- Do Not Resuscitate Form if desired
An advanced directive/Living Will will address things like….I want or I do not want…a ventilator for breathing, a feeding tube, blood transfusions, dialysis, antibiotics, Surgery, life support treatments, pain management strategies.
Decide if you want a Do Not Resuscitate (DNR) order or not. If your heart or breathing should stop a DNR order will express the desire to not be revived.Below is a critical point!!!! (You would be surprised how many DNR patients get resuscitated.)
In a study about properly executed DNR orders, the medical records of 180 admissions over 3 years, 1991 through 1993, were reviewed for documentation of patients’ advance directive status. The findings showed that only 26% of patients who had previously executed advance directives had their directives recognized during their hospitalization. JAMA 1995 Morrison et al. Sometimes a DNR order is not followed because it is hard to know if a patient has a DNR order in a life threatening moment. So one solution is to plan ahead.
- If you are a DNR patient make sure you have the pre hospital DNR laminated and signed by your Doctor and displayed prominently on your fridge. Then have a prominent bracelet that displays you are a DNR patient and states the signed forms are on the fridge. Otherwise the default is for Medics/First Responders to resuscitate you by law in most states.
- If your family member is a DNR patient and in a nursing home or assisted living facility make sure the forms are signed and on the fridge or tacked on a wall above the bed. Also make sure the family member has a DNR bracelet and it states the signed forms on on the fridge or tacked to a wall above the bed.
A DNR order is separate from an Advance Directive/Living Will, even if your Living Will states that you do not want life-support treatments at the end of your life. If you’d like to have a DNR order, you’ll need to meet with your doctor to complete the forms.
These forms differ from state to state.
State-by-State Advance Directive For DNR forms are online as well but need to be signed by the patient, the surrogate, and the Doctor.
Having these desires known and signed by the proper people save so much pain and heartache to the patient, family, and health care staff. Hospice can be a godsend for patients in helping them have comfort with pain medications and not extensive side effects of myriad medicines that may prolong somebody’s life only a few weeks or months and make them profoundly sick.
Ask to have a physician and nurse assigned to you that specialize in end of life and palliative care. They are extremely knowledgeable how to help you improve your end of life quality of life profoundly!
Of course these are deeply personal decisions but the discussions must be had. If a patient wants to treat their terminal condition aggressively to prolong their life prolonged that is wonderful. If a patient chooses to have less side effects from myriad medications and a shortened life that is wonderful too. Let’s just have the discussion. Let’s find out what a patient really wants at the end of their journey here on this earth.