End-of-Life Decision-Making - Withholding Vs Withdrawing Treatment

By David Lemberg

Families will struggle with these choices, regardless of whether withholding or withdrawing treatment is being considered. For the ethics consultant, it's good to begin with the understanding that withholding and withdrawing are moral and ethical equivalents. That clears the playing field.

It seems likely that family members who are guilt-ridden - for all the things they did to and for the dying relative and all the things they didn't do - will have great difficulty with any of these choices. As they're losing their relative permanently, all the past can now never be made right. So there's a strong tendency to hold on regardless of the medical circumstances.

Such individuals could never be "responsible" for any proactive choice that would result in their relative's demise. As long as the relative lives, the family member's fantasy of resolving the guilt can continue. And, in no way could they be able to pile on more imagined guilt than they already have.

Withholding treatment might be more palatable, as the family member is only agreeing to the status quo. Withdrawing treatment would require taking action that would change the present circumstances. The family member cannot take on that responsibility in the face of the unresolved issues.

For the most likely small minority of families who are able to let their loved ones go in a humane and medically responsible manner, such questions might not arise.

Matters of withholding or withdrawing treatment depend on the specifics of the case. If there are reasonable expectations regarding quality and length of life, then beginning treatment with targeted reevaluation is appropriate. Withdrawal might be considered at a later date.

If the prognosis is poor from all points of view, and lifesaving measures would only keep the body alive with no other prospects, then withholding treatment seems most appropriate.

Of course, these are hypotheticals and necessarily sketchy.

A fresh perspective may be obtained by considering that our current medical expertise is only a modest upgrade from the days of leeches and bleeding patients. If the human race lasts another 300 years, future physicians and concerned citizens will look back on the 21st century with much of the same horror and bemusement with which we view early 18th-century medicine.

Cancer treatment provides a bracing context. Chemotherapy, ablative surgery, and radiation may be eventually viewed as barbaric rather than "heroic". From another viewpoint, these methods may be the best we have right now. But that doesn't suggest they should be used in all cases. Case-by-case evaluation and treatment would be the most humane approach.

Similarly with percutaneous endoscopic gastrostomy (PEG)tubing. Whereas these may be useful in the ICU in cases in which survival and quality of life are real considerations, such methods of artificial nutrition/hydration are not appropriate merely for ensuring continued life. What's the value of being alive when you're mostly dead?

In clinical bioethics, nothing is straightforward. It is critically important to have an open mind and leave one's prejudices and preconceptions at the hospital entranceway.

David Lemberg, M.S. in Bioethics, Albany Medical College, May 2010
Consultant, Author, Speaker. Research interests - health care and health care policy, reproductive technologies, genetics and genomics, K-12 science education
Executive Producer, SCIENCE AND SOCIETY, http://scienceandsociety.net
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For more information, you might enjoy reading my book, More Than Meets the Eye True Stories about Death, Dying, and Afterlife. Purchase paperback on Amazon.com. It's also on Amazon as an e-book for those who have Kindle or Sony Readers. The audio book is now available!

End-of-Life Decision Making For Cancer Patients

By Pauline Go

People who are in the last stages of cancer should pay some attention to end-of-life decisions. The most important is advance directive, also known as living will, for medical treatment. This is nothing but a document written by the terminally ill person while he or she is still capable of making decisions. The advance directive basically states that the patient does not want artificial means of surviving should he or she become mentally incompetent. Artificial life saving measures include CPR, respirators or anything else the person can think of.

The reason why advance directive only applies to a person who in mentally incapable of making decisions is because prior to that a doctor can ask the person what his or her preferences are about the treatment. However, once the person becomes mentally incompetent, he cannot be asked to state to state his or her preference.

However, advance directive is not only about dying with dignity. There are some patients who might want to live as long as possible using CPR or artificial breathing machines. If this is mentioned in your living will, the doctors and your family would have to respect it. In fact, the doctor would have to do everything to save your life or prolong it.

Those who find writing advance directive morbid, do not have to do it. Instead they can appoint a health care agent. This is someone who makes all the healthcare decisions on your behalf when you are incapable of making them. However, you would have to tell the agent what your wishes are while you are still able to think and comprehend coherently.

Pauline Go is an online leading expert medical industry. She also offers top quality articles like:
Lung Cancer Facts,
Bone Cancer Symptoms
Article Source: http://EzineArticles.com/2184874

~~~~~~~~~~~~~~~~~~~For more information, you might enjoy reading my book, More Than Meets the Eye True Stories about Death, Dying, and Afterlife. Purchase paperback on Amazon.com. It's also on Amazon as an e-book for those who have Kindle or Sony Readers. The audio book is now available!
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A Memorable Death

Marvin is 55 years old and he has a brain tumour. He is getting physically weaker by the day and is now having difficulty in breathing. However, he is still mentally very alert.

Although Marvin knows that death is imminent, he does not seem to fear death, at least not outwardly. As he is not talking very much about his impending death, I take it as a sign that he or those around him have not fully accepted the reality of his situation. I personally feel if this hurdle is overcome, it would make a tremendous change for all.

Good or bad deaths

For the past 17 years, I have witnessed countless deaths. To simplify my observation, some deaths can be termed as “good” or easy while a small number are considered “bad” or difficult.

William was 44 years old when he was diagnosed to have kidney cancer. As his cancer ravaged his bones and liver, he became physically weaker. Refusing to believe that his death was near, he fought it all the way. Each day, he harboured hope for a cure and he was constantly searching for it. He was angry with his doctors because they could not offer him a cure and so he directed his hope towards alternative treatments. Despite trying various types of alternative treatments, he succumbed to his disease.

William had a difficult time as he was dying. From the numerous house visits, I could see that he was afraid to face death and to accept his own mortality. He was fearful of the unknown after death. What was there waiting for him? Would he exist after death?

He diverted his remaining energy resisting, resulting in more frustrations and despair. (describe his last moments to show the contrast between good and bad deaths)

In contrast, 72-year old Jane who was a former nurse had a peaceful death. She died from a terminal chronic obstructive airway disease as a result of heavy smoking during her younger days.

Towards the end of her days, Jane accepted that she was dying and instructed her loved ones not to attempt any heroic resuscitation on her. Instead, they should let her go naturally and peacefully.

Common characteristics

In short, a good death can be achieved when a person is fully accepting that death is inevitable and that it’s a part of the living process. Better still if he/she believes that we are in essence spiritual beings, not just a physical entity.

By fully accepting death and it being a part of a life cycle, we would not cling on to our dying body. This process allows us to let go of our attachments to this physical existence. It lets us focus our remaining energy to prepare ourselves for the next step - the transition into another existence. Whether you believe in a single life or many lives and rebirth, the next step is essentially a transition from a physical existence to a spiritual one.

That brings us to the knowledge or belief in our spirituality. Without this, it is truly very difficult to see death in a positive way. When we believe in our spirituality, or when we know deep within that we are essentially a spiritual being, then death can even be something to look forward to. After all, discarding an old and weak physical body that is full of pain for something newer and better should not be too difficult.

Thus, whether we are going to experience an easy death or a difficult one depends on how we view death and how we view ourselves.

There is no pain in death

One of the things most dying people are afraid of is the belief that death may be painful. The truth is that death is painless. This is true regardless of whether you are experiencing a good or a difficult death.

Pain is a physical sensation. It only exists as long as the physical body is intact. At the point of death, there is no pain as the physical body cannot feel anymore physical sensation. Thus even if one is suffering from severe bone pain as a result of the cancer spreading to the bones, the final moment is pain-free. It was evident in Marvin’s last breath.

Bring It Out In the Open

Death is a subject that is difficult for most people to talk about, yet when one is dying, the urgency is there. This is true for the dying as well as for his loved ones.

Talking about death and acknowledging it openly make it easier for all involved to accept death as a natural part of the living process. This acceptance helps the dying to let go of his attachments to his own physical body as well as his attachments to those around him. Likewise, it allows his loved ones to let him go in peace, instead of clinging on to him. Not allowing a dying person to go peacefully can cause him to hang on unnecessarily and make it more difficult for him to go peacefully.

A Memorable Death

In some ancient cultures, death is not seen as something dreadful. In fact, it is an event that is worth celebrating. After all, shouldn’t we be happy that we are “going home”?

This reminds me of a memorable death of an old lady. She was the mother of one of my regular patients. Being a very religious person, she had approached death in accordance to her faith. During her last hours, a group of her friends was present to chant sermons for her. Soothing recordings of the chanting were also played continuously as the old lady waited for her final moments.

According to her loved ones, she looked radiant when she passed away and all those present were able to sense her departure. The old lady had turned her death into a joyous event!

Learning from this, perhaps we should all remind ourselves that death need not be a dreadful thing and that we can turn it into a joyous and spiritual occasion. We do have a choice, even in death.

Dr. Tim Ong is a medical doctor who runs his own busy medical practice. In his free time, he enjoys giving public talks, teaching meditation and offering his service to hospice work in the community. He is also the webmaster of The Self Improvement Site and Mind Science Info. He also gives away his personal collection of life transforming ebooks at Book of Transformation.

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For more information, you might enjoy reading the complete book More Than Meets the Eye True Stories about Death, Dying, and Afterlife. Purchase on Amazon.com

Staying out of the Freezer

My aunt Kat lives with her sister, who is my mom’s twin, Dot. Kat was fast approaching the eight month since being diagnosed with terminal lung cancer. In hospice care at home, she was not feeling well the day her mom’s (my grandmother, whom we call Nanny) 94th birthday came around. Nanny lives with my mom and dad about 20 minutes from Dot and Kat.

My mom and Dot had a lot of work to do in preparation for Nanny’s birthday party. Food had to be cooked, my mom’s house had to be cleaned, and decorations had to be installed before the 50-plus guests arrived. Kat was too weak to drive, so she would have to ride with Dot a few hours ahead of party time so Dot could help my mom get everything ready.

Kat wanted to stay home because she didn’t feel like joining in the festivities, but Dot wouldn’t hear of it.

“I feel so bad, I could just die,” Kat told Dot.

“You can’t die today,” Dot said. “We’ve got too much to do! If you die today, we’ll have to put your body in the freezer until tomorrow!”

Kat went to the party. Upon arriving, my mom asked her, “How are you feeling today?”

“I’m just trying to stay out of the freezer.” Both sisters laughed.

Eleven months have passed since Kat received the news that she probably had six to nine months to live. Knowing that the disease will eventually take her life, she says every day is a miracle. I agree.

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For more information, you might enjoy reading the complete book More Than Meets the Eye True Stories about Death, Dying, and Afterlife available on Amazon.com.

Update on My Aunt and Nanny

If you've kept up with my blog for a while, you may know that my aunt, Kat, is dealing with terminal lung cancer. She has already outlived the six to eight months the doctor expected she might last when she saw him last November. Kat refused to have any more chemo or radiation and has been in hospice at home where she lives with her sister, Dot (my mom's twin). A hospice nurse comes by once a week to check her progress. Or, should I say demise? No, for a while Kat stayed at a plateau and didn't get worse or better. I think she was on hold until my grandmother, whom we call Nanny, decided if she was going to live or die. It seems to me that Kat and Nanny may have a contract to leave this world together or at least near the same time.

Nanny fell and broke her arm and hip last November, but made miraculous recovery after two hip surgeries. She was about to start physical therapy and learn how to safely put weight on the still-healing leg, when she got a urinary tract infection. The doctor put her on an antibiotic called Macrobid. The drug nearly killed her when she had a cardiac reaction to it. She was on the verge of having a stroke when my mom (her live-in caregiver) called for an ambulance. After spending several days in the hospital, Nanny came home on Wednesday. However, she was again taken to the hospital last night. There is fluid around her heart and the spinal vertebrae that she injured in 1976 is deteriorating and causing significant pain every time she moves.

About two weeks ago, Kat's health began taking a decline. She had been having headaches all along, but they became so bad that a stronger medication was added to the menagerie of drugs she is already taking. She got an upper respiratory infection, possibly pneumonia, but since she is in hospice, she doesn't see a doctor. The hospice nurse prescribed an antibiotic that helped some. At least she is able to sit up long enough to send me a funny or sweet email.

Despite the fact that she is on a constant and high intake of oxygen, her blood saturation level stays in the upper eighties and she feels weak most of the time. So weak that hospice offered her a walker to help her get around in the house. She doesn't want a walker. Hell, that's like admitting that she is approaching another stage of the dying process. She also refused to have a hospital bed at home, but Dot vetoed that decision. Kat is now using the motorized bed and recliner that were delivered two weeks ago. I think she likes playing with buttons and making the bed go up and down. In her condition, that's about as exciting as being on a roller coaster.

Nanny and Kat live about 20 minutes from one another. Kat still tries to make the trip once per week to see Nanny and let her know that she's still alive. They talk on the phone several times daily, and never go to bed at night until they tell one another "goodnight and I love you." So sweet. I love my family.

The twin sisters have it hard right now. Both are living with and caring for a relative who is fighting to stay alive. Dot recently retired from her day job so she could tend to her younger sister while my mom tends to Nanny. I live 250 miles away and don't get to Atlanta as often as I need and want to.

I'm supposed to leave for vacation next Friday. I'll be out of the country for a week. Kat and Nanny, please don't die while I'm gone. I'm coming down for a visit when I get back from Dominica Republic. Just hold on.

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For more information, you might enjoy reading the complete book More Than Meets the Eye True Stories about Death, Dying, and Afterlife available on Amazon.com.

Spirit Guides, Deceased Loved Ones, and the Afterlife

I spoke to my Aunt Kat last Sunday. She was in good spirit and has a good mind--even though she says cancer is killing her brain cells. We were able to laugh as we chatted about dying. She and I both are able comfortable talking about the afterlife. She plans to visit me once her spirit leaves her body, which will probably be soon. Her health is failing and she is entering the latter stages of her battle with lung cancer.

She says she will give me the sign of a cameo or silhouette to let me know she is contacting me from the other side. As much as I hate to lose her in physical form, I'm actually looking forward to having her near me in spirit, and hope she will visit me often. Even though Kat still clings to her Christian views, she is open to communication from the other side. I suppose she has heard her mom (Nanny) talk about her "visitors" so many times that it is a natural and acceptable to believe.

Nanny, now age 94, had a near-death experience (NDE) when she was in her thirties. In the NDE, she communicated directly with angels who told her she had to come back to earth and finish raising her children. Until recently, Nanny rarely spoke of it with anyone but my mother and me. Probably because I have had two NDEs and totally understand and believe her. And, mom? Well, she doesn't say much one way or the other about it. I'm not sure if she sees in the spirit and doesn't admit it, or if she's just humoring me and Nanny.

As Nanny's life is coming to a close, she frequently shares that she sees and talks to her husband and son, her siblings, and her own mother from the spirit realm. In the past 10 months (since she fell, broke her hip and arm, and had two surgeries to repair the damage), she's been seeing angels and spirit guides more often than before. The messages they deliver bring encouragement that her time on earth is short and that everything on the other side is set for her arrival. Seems like an entourage is waiting for her there. It will be sad to see her leave us, but it is comforting to know that she will be reunited with loved ones when she passes through the veil. I don't think Nanny has any plans to visit me from the spirit realm. She's too excited about getting to the "other" folks!

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For more information, you might enjoy reading the complete book More Than Meets the Eye True Stories about Death, Dying, and Afterlife available on Amazon.com.