What is Life-Sustaining Treatment?
Advances in medical treatments and technologies can often create medical dilemmas. For example, certain treatments can be lifesaving and can bring a person back to their previous level of function and independence. However, some treatments can also be harsh, especially for people already in poor health. Some intense treatments, when used for people who are seriously ill, can cause inconvenience, pain, and suffering. These treatment options can include kidney dialysis, feeding tubes, ventilators to artificially support breathing, and CPR (cardiopulmonary resuscitation) to revive the heart after a cardiac arrest. In many cases, these treatments may prolong life but will not cure or improve conditions such as advanced cancers or advanced dementias, or improve quality of life.
In some cases, clinicians may refuse to provide treatment if, for example:
- There is no medical rationale for the treatment
- The treatment has proved ineffective for the person
- The person is unconscious and will likely die in a matter of hours or days even if the treatment is given
- The expected survival is very low
Treatments that have been started can always be stopped. Stopping or withdrawing life-sustaining treatments is appropriate if those treatments are not beneficial, or are not consistent with an individual’s wishes and priorities in life.
Even if life-sustaining treatments have been refused or stopped, the individual can still receive medical care to treat symptoms such as pain or shortness of breath.
Life-sustaining treatments and advance directives
Because many illnesses and complications cannot be anticipated, it is extremely important to have advance directives. Timely completion of these documents can help prevent unwanted burdensome treatments at the end of life. It is also important to discuss your advance directives with your family or friends. Rather than trying to anticipate specific scenarios, think about your goals for the time at the end of your life. For example:
- Is your goal to prolong your life by all medically effective means?
- Is your goal to treat medical conditions, but avoid difficult measures?
- Is your goal to maximize your comfort?
- Is your goal to maintain quality of life, including the ability to do tasks you enjoy?
These are highly individual decisions, but they are very important for guiding your clinicians in providing treatments that are consistent with your goals and wishes. They will also help guide the people you have chosen to make medical decisions on your behalf if you are not able to do so.
End of Life Symptoms
There are symptoms that are common at the end of life, and these can be distressing to family and caregivers. These include loss of appetite, breathlessness, and/or loud respiration/breathing. There are several non-medical strategies to ease someone’s discomfort at the end of life.
- Loss of appetite (anorexia) is an almost universal symptom in individuals who are dying. Appetite stimulants and tube-feeding do not prolong survival and should not be used. Ice chips, ice pops, moist swabs, or artificial saliva can help prevent the mouth from becoming dry and cracked.
- Breathlessness (also known as dyspnea) at the end of life is common and often distressing. Individuals can feel breathless even if their breathing and oxygen levels are normal. Moving cool air across the face from a window or with a fan can be helpful. Oxygen therapy and, in some cases, medications can also help.
- Terminal respiratory secretions (known as a“death rattle”) are a sign that death is close. These sounds are caused by fluid that collects in the back of the throat and windpipe in individuals who no longer have a swallowing or cough reflex. Repositioning and elevating the head of the bed can be helpful. Gentle suctioning and medications to dry up secretions may also be used.
Care and Treatment
Palliative Care
Palliative care is specialized medical care that focuses on relieving pain and other symptoms of illness. Palliative care is appropriate for any person with a serious illness, regardless of the stage of the disease or how long the person is expected to live. Palliative care can be provided by a primary care provider or a specialist with extra training in this field to help treat more difficult symptoms.
Hospice Care
Hospice care is specialized care for people who are believed to have a life expectancy of 6 months or less. Accepting hospice care means shifting from the use of medical treatments to prolong life as much as possible toward a focus on treating symptoms and improving quality of whatever life remains for a person. Hospice care can be provided at a person’s home, or at a nursing home or inpatient hospice facility. The care is provided by a team that includes a physician or nurse practitioner, nurse, home health aide, social worker, chaplain, and volunteer. Although these team members provide regular visits and 24/7 phone availability, the majority of care for people receiving hospice care is provided by family, friends, or care teams at a facility.
End-of-Life Considerations
Do-Not-Resuscitate (DNR) Orders
CPR (cardiopulmonary resuscitation) may be an effective treatment for unexpected sudden death, but it is not effective or appropriate for people who are near the end of life. A “Do-Not-Resuscitate” (or “DNR”) order can be written by your clinician to help make sure you don’t receive unwanted CPR. Individuals who have an implantable cardioverter defibrillator (ICD) should talk with their providers about turning these devices off at the end of life to avoid painful, inappropriate shocks.
Orders for Life-Sustaining Treatment
Most states now have initiatives to improve end-of-life care by using forms that put a person’s goals and preferences into medical orders that a clinician must follow. These forms are different from advance directives and are most appropriate for individuals who are seriously ill. These forms have various names including:
- Physician Orders for Life-Sustaining Treatment (POLST)
- Medical Orders for Life-Sustaining Treatment (MOLST)
- Physician Orders for Scope of Treatment (POST)
- Medical Orders for Scope of Treatment (MOST)
You can find the POLST form appropriate for your state by accessing the National POLST website.
Artificial Feeding and Hydration
Decreased eating and drinking is common among people who are seriously ill and near the end of life. This can be extremely distressing for families or caregivers, who may want to provide food and water artificially, such as through intravenous lines or a feeding tube. Although food and drink should always be offered by mouth to a person who is seriously ill or dying, artificial feeding and hydration may cause discomfort to someone whose body is no longer processing food and liquids normally.
Medical Aid in Dying
A small number of states now have laws that permit physicians to prescribe medications that allow terminally ill individuals to end their lives. The life-ending medications must be administered by the individual themselves, not by another person. Oregon was the first state to legalize aid-in-dying. However, data show that among people who get the medications to end their lives, many ultimately do not use them.
Last Updated July 2020