End-of-life care

Council on Ethical and Judicial Affairs American Medical Association. Medical futility in end-of-life care. JAMA 1999, 281, 937-941. 

Foley, K., and Hendin, H., Eds. 2002. The Case Against Assisted Suicide For the Right to End-of-Life Care. Baltimore, MD The Johns Hopkins University Press. 

In developed countries, cancer treatment centers should have access to pain specialists who can manage the complex issues involved in cancer pain, including changing medication requirements, changes in metabolism and pharmacokinetics of medications related to cancer treatments, and the tradeoffs between comfort and sedation frequently involved in end-of-life care. A large Italian study showed that access to palliative/supportive care teams was associated with a 31% lower chance of suffering severe pain during cancer care [42]. 

Pain management should not be limited in end of life care. 

Both the respiratory system and other comorbidities, especially cardiovascular conditions, should be stable so that ventilator settings and oxygenation no longer require regular medical intervention. The only exception is the patient returning home for end-of-life care, who may be discharged once a palliative care plan is in place. 

Table 2 Components of Palliative and End-of-Life Care for Patients with CardiopiilmonaTy Disease...

Management of the dying process, including withdrawal of life-sustaining treatment Referral to appropriate hospital and community resources Quality palliative and end-of-life care in all treatment settings Responsibility of the professional caregiver... 

Assurance of education and competence in palliative and end-of-life care Support and counseling to address professional caregiver grieving Development of institutional, professional, and regulatory policies to ensure quality Palliative and end-of-life care... 

In this case, the patient and his family had initially chosen a very active level of eare, including transplantation. When his respiratory condition worsened and they had to make another decision regarding the intensity of therapy in the face of apparently irreversihle disease, they chose a time-limited trial of intuhation. Patients often tell us they do not want to be on a long-term ventilator, but they would like a trial to see if some part of the ehnie picture is reversible. Chronie rejeetion meant this patient s survival off the ventilator was not possible, and the patient and his family elected to prioritize comfort care. The morphine drip was begun as part of the patient s end-of-life care, and to the surprise of his family and... 

Knauft E, Nielsen EL, Engelberg RA. Barriers and facilitators to end-of-life care communication for patients with COPD. Chest 2005 127 2188-2196. 

Selecky PA, Eliasson AH, Hall RI, et al. Palliative and end-of-life care for patients with cardiopulmonary diseases—American college of chest physicians position statement. Chest 2005 128 3599-3610. 

Singer PA, Martin DK, Kelner M. Quality end-of-life care patients perspectives. JAMA 1999 281 163-168. 

Tmog RD, Cist AEM, Brackett SE, et al. Recommendations for end-of-life care in the intensive care unit The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 2001 29 2332-2348. 

In my opinion, the prevalent misconception of the progression of immobility as the signal for end-of-life care is the reason morphine sulfate and oxygen were given as a substitute for NPPV. I observed that these two treatments were often administered by hospices in successful users of NPPV. This was based on their perspective that since ALS is fatal, and that their protocols are the treatment of choice, rather than the optimal use of NPPV and airway clearance. In addition, some hospices consider that NPPV should be used intermittently to provide comfort only and not to extend survival. Furthermore, the use of bi-level ventilators by hospices, without backup rates, has increased for ALS patients. The hospice nurses had based their opinion on the belief that backup rates promote survival and had not understood that a backup is necessary for optimal relief of h)rpoventilation. 

Prendergast TJ, Claessens MX, Luce JM. A national survey of end-of- life care for critically ill patients. Am J Respir Crit Care Med 1998 158 1163-1167. 

McDonagh JR, Elliott TB, Engelberg RA, et al. Family satisfaction with family conferences about end-of-life care in the ICU increased proportion of family speech is associated with increased satisfaction. Crit Care Med 2004 32 1484-1488. 

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