End of Life Care
Medicine today has the power to prolong life in two different ways. Many of us will live longer and fuller life spans because of medical advances, lifesaving interventions, and new prevention knowledge. Others of us will find our last days and months prolonged—sometimes in an unwelcome way—by life support technology and practices that enhance neither the quality of our lives nor our deaths.
Life support can breathe for us, eat for us, and substitute for vital organs. Sometimes a partial (or full) recovery from a terminal illness or incapacitated state is possible; but even when there is no hope of revival, doctors may sometimes take extraordinary measures. Some say that these choices derive from doctors' training in resisting death at any cost, others point to liability risks if any potentially curative intervention is overlooked. Not infrequently, requests to prolong life at any cost are also voiced by patients themselves and more often, their families. But increasingly, doctors, along with patients and family members, fail to recognize when curative technology is no longer indicated and a different technology—end of life care—should be brought into play.
Talk of dignity, quality, and sanctity of life has been heard ever more frequently in hospitals, medical schools, and the media. These terms have different meanings for each of us, and can sometimes be used as arguments for or against life support. At the same time, dignity and quality of life are important to all of us, especially when we are very ill and potentially near the end of our lives. So who should decide what care is life-saving as opposed to death-prolonging? You.
There are a great many considerations to end of life care, including: emotional and philosophical concerns, deciding where to receive care, and legal options. The one thing that everyone agrees on is that each of us should ponder, discuss, and legally establish our approach to the management of life-threatening illness before a medical crisis occurs.
Emotional and Philosophical Matters
You can begin by asking yourself some tough emotional questions. What are your fears: pain, loss of dignity, machines keeping you alive, or dying in a strange place? Fill in the blank: "My life is only worth living if I can ___". Is life defined by a heart beat or a working brain? Whom do you want to make decisions for you if you are not able to communicate? Discuss options with your doctor. Seek guidance from your religious leader. Talk with family. Above all, make sure that family members know what your choices would be under a variety of serious situations; if possible, put your choices and values into writing.
Care Options
The last days of life can be spent in your home, a nursing facility or a hospital. These facilities generally seek to cure, rehabilitate, or support life. If you are seeking curative care or aggressive medical treatment, a hospital is usually the best choice. Today many hospitals are adept at balancing curative and palliative care when the end of life approaches. Palliative care, perhaps most often given in the hospice setting, provides treatment that enhances comfort and quality during the last days of life. This type of care seeks neither to hasten nor to postpone death, but rather to provide relief from pain and discomfort. While services may vary from community to community, in many parts of the country palliative care can be supplied either in a hospice facility or in your home. Also, more and more hospitals and medical centers employ palliative care specialists, so make sure you inquire about them when you are hospitalized. They will not only make sure your care is tailored to what you, as a patient, need, but they will also help you make the crucial decisions and provide support for your family.
Legal Options
For most of us it is very hard to imagine how we are likely to feel when faced with a serious and potentially fatal illness or injury. It is perhaps only human nature to prefer to wait until the crisis is upon us and then communicate our intentions to the nurses and doctors providing our care. Unfortunately, there are many scenarios that can interfere with one's ability to communicate. For example, it is impossible to tell a doctor your treatment decision while on a ventilator (mechanical breathing apparatus) or when unconscious. Fortunately, there are legal solutions to this problem. Among these legal solutions are:
- Advance directives
- Health care proxies
- Living wills
- Do not resuscitate orders
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