Making Decisions about end-or-life care
There are different ways in which your condition might be described when you are unable to make your own health care decisions; there are also a number of life-sustaining treatments that you may or may not elect to choose. Listed below are definitions of these conditions and treatments to help you make your health care decisions.
A person is considered to be incapacitated when, in the opinion of the attending physician, he or she is unable to understand the nature and consequences of health care decisions and is unable to communicate an informed decision.
Permanently Unconscious (Permanent Vegetative State)
A person is considered to be permanently unconscious when his or her condition is irreversible and he or she 1) is at no time aware of himself or herself or the environment; and 2) shows no behavioral response to the environment.
Other important provisions of Connecticut law concerning health care decision-making include the following:
medical care cannot be conditioned on whether an individual has or does not have an advance directive
medical providers cannot make any assumptions about an individual’s wishes if he or she has chosen not to complete an advance directive
even individuals who choose to forego medical care have the right to receive comfort care and to have their pain controlled
if a medical provider is unable or unwilling to follow an advance directive, the provider must arrange to transfer the involved individual to a provider that can do so
Connecticut now recognizes advance directives from other states and even foreign countries
A terminal condition means the final stage of an incurable or irreversible medical condition which, unless life support is administered, will result in death within a relatively short period of time.
Cardiopulmonary Resuscitation (CPR)
CPR is used when a person’s heart and/or breathing stops. CPR may include applying force to the chest with the hands, electrical shock to the heart, injection of medications and the use of a mechanical respirator. Every person receives CPR when his or her heart stops upon admission to a medical facility, when emergency services are contacted through 911 or when medical attention is sought unless a Do Not Resuscitate (DNR) order is present. To resuscitate when an individual has a DNR order in place may represent a violation of a person’s preferences or right to die with dignity. Refer to the next page for additional information about DNRs.
Mechanical ventilation is used when a person can no longer breathe naturally. A breathing tube may be inserted and a ventilator utilized after an individual is resuscitated through CPR when mechanical ventilation is needed to maintain breathing. Individuals in this situation often become dependent on mechanical ventilation, never regaining the ability to breathe naturally and being at risk of developing complications such as pneumonia. Mechanical ventilation can also be used to support breathing during a short-term acute illness or after an accident until the individual has recovered. Mechanical ventilation cannot, however, provide a cure or restore breathing functions for persons who are terminally ill with conditions that affect their ability to breathe naturally or for those who are in a Persistent Vegetative State.
Artificial Hydration and Nutrition
When a person can no longer take food or fluid by mouth, these nutrients can be administered artificially through several different mechanisms; namely,
A Nasogastric Tube that is inserted through the nose, down the esophagus and into the stomach.
A Gastrostomy Tube that is inserted surgically through the skin of the abdomen into the stomach.
Liquid nutrition, water and medication may be administered through a gastrostomy tube or a nasogastric tube.
An Intravenous (IV) Hydration line that is inserted through a needle into a vein.Fluids and medications flow through tubing into the vein.
Whether to withhold or withdraw artificial nutrition and hydration is one of the most painful decisions of end-of-life care. The question becomes whether the absence of artificial nutrition and hydration causes suffering as a result of starvation and dehydration. As the end of life approaches, the body requires little or no food. Research has shown that prolonged use of intravenous fluids and/or artificial nutrition is usually not effective and can even complicate a person’s care. Medical evidence regarding dehydration at the end stage of a terminal illness indicates that it is a very natural and compassionate way to die. In fact, it may help to make breathing easier and may reduce discomfort or suffering.
Do Not Resuscitate Order (DNR)
A separate type of advance directive is a Do Not Resuscitate Order (DNR), which directs medical personnel not to perform CPR or other life-saving procedures on an individual experiencing one or more body system failures. A DNR order requires a special signature from this person’s physician and can only be signed with the consent of the person or of his or her authorized representative. Persons may have active DNR orders when they are in the hospital or in another health care facility, or when they are living at home and have a terminal illness. Having a DNR order does not prevent a person from receiving treatment for pain and other comfort measures. The order only applies to performing lifesaving resuscitation measures like CPR.