The one thing that is inevitable in life is death. Doctors know that we can do everything humanly possible to delay death with our medications and interventions, but in the end death always wins. This is why an important part of the practice of medicine is guiding patients and their families through the dying process. Our culture in the Philippines is very family-centric and so relatives are almost always involved in end-of-life decisions. Since this is a predominantly Catholic country, there is always the hope of a miracle.
Our faith however can sometimes give unrealistic expectations which can lead to unnecessary futile interventions that prolong the dying process. There is nothing wrong with hoping and praying for a loved one to get better, but in many instances, it may really be a person’s time to go in the natural order of things.
Euthanasia and assisted suicide are illegal in the Philippines, so this is always a nonstarter for Filipino doctors. No doctor in our country should offer to actively end the life of a patient. What should be made clear though, is that there is an important distinction between allowing a person to die, which is a completely natural process; versus hastening death with drugs, which is not ethical.
Many doctors are still uncomfortable with end-of-life discussions. After all, our training is geared towards doing everything to save the patient. It is important to recognize however when interventions are futile, and it is important to help the patient and the family understand which treatments may work and which ones won’t. The best way to make sure that a patient’s dying wishes are carried out is to prepare advanced directives while the patient is still able to communicate his or her preferences. Advanced directives are a set of instructions that tell doctors and healthcare workers how far we should go with our interventions when a person becomes unable to communicate. This includes whether the patient wants extraordinary measures if he or she stops breathing or his or her heart stops beating.
Hollywood and too many TV episodes and movies have painted an unrealistic expectation of cardiopulmonary resuscitation, or CPR. Almost everyone in these fictional shows is revived by pumping on the chest and giving a few rescue breaths.
The reality is much grimmer. Only one in six people who undergo CPR will be discharged from the hospital alive, most with neurologic complications and almost never back to normal. Most patients who do survive post-CPR are young, healthy, and have no underlying illnesses. For those who are chronically ill or who have terminal diagnoses like advanced cancer, CPR survival is about one to two percent. Most of that tiny number who are successfully revived will die shortly after.
Therefore, in patients who are terminally ill, it is important to discuss how far the patient wants doctors to go. CPR is not innocuous and can result in broken ribs and significant pain. If the chances of long-term survival are miniscule, many patients opt to sign a do not resuscitate (DNR) advanced directive if his or her heart stops. Other advanced interventions include putting someone on a ventilator and having a machine take over breathing through a tube inserted into the throat. This can significantly prolong the dying process without affecting overall survival, and so some patients who do not want this done sign a do not intubate (DNI) advanced directive. I always explain to my medical students and trainees that DNR and DNI orders are never euthanasia or assisted suicide. Doing CPR and placing someone on a mechanical ventilator are considered heroic measures. These can be appropriate in patients who have a reasonable chance for survival. In chronically ill patients in whom the likelihood of long-term survival is very low, however, it is reasonable that some patients choose to forego these interventions as they are extraordinary measures to prolong life. DNR and DNI allow a patient to die, which is part of the natural process in terminally ill people.
In the event that there are no advanced directives and the patient is unable to communicate his wishes, doctors turn to the patient’s family to make decisions. Typically, the hierarchy for decision making is the person’s spouse if any, followed by adult children, then parents, then siblings and then other relatives in terms of degree of consanguinity. This is much more difficult when there are many family members with different opinions on what should be done. One useful technique when helping family members decide is to remind them that they should make the decision based on what they think the patient would want as they know him, rather than what they themselves want. Different family members will have different kinds of relationships with the patient and may also have their own beliefs and motivations for making decisions. Focusing on the patient’s wishes gives everyone a good starting point to come to a consensus.
The decision for DNR and DNI should always start with an accurate diagnosis and prognosis of the patient. A young healthy person with no terminal illnesses who develops a potentially reversible severe condition should probably not be under a DNR/DNI directive as there is a reasonable chance for survival. Patients with advanced cancer or who are chronically debilitated with poor functional capacity will not likely survive a terminal event like a cardiac arrest, and so DNR and DNI are appropriate decisions. There are other grey areas in terms of interventions, such as dialysis, the use of pressors (medications that artificially maintain adequate blood pressure), antibiotics, and other supportive measures. Pain control in patients who have painful conditions like bone pain from metastatic cancer is a must, and should be aggressively pursued to ease the dying process. These have many more nuances in terms of value of each of these interventions and whether the family thinks the patient would want them. We should remember that many of these are extraordinary measures and so withholding them isn’t unnatural. In fact, it allows nature to take its course through the dying process. Finally, the patient and the family can always change their mind at any time if they are uncertain about some aspect of the interventions. Good communication with your doctor will go a long way towards having peace of mind during this difficult process.
Finally, the spiritual aspect is always a good source of comfort for patients and their families. Visits by a chaplain or a religious worker help ease the dying process. I encourage family members to spend as much time as possible with their loved one, even when the patient is comatose. Familiar voices can still reach the patient in many cases, and talking to an unresponsive patient can also give comfort to the family member. There is nothing easy about the process of dying, but we can make it as peaceful and natural as possible.