Article Series

So You Say You Want to Die in Peace - Part 2

Article submitted by Bart Windrum, author and speaker.

Link to Part 1

So You Say You Want to Die in Peace - Part 2

Several months ago I introduced the topic of dying in peace and listed a range of aspects we each ought to address to increase our likelihood of achieving the peaceful death that most of us say we want, yet generally fail to achieve. This month we continue our unvarnished look at factors contributing to a non-peaceful demise with a topic is one that’s crucial to understand. I have yet to encounter an advance, comprehensive discussion of it: all things related to resuscitation. It’s too big a topic for one article (my book, Notes from the Waiting Room: Managing a Loved One’s (End of Life) Hospitalization devotes a full chapter to it). This article is devoted to a look at life support technology (I’ll abbreviate it as LST) and the various ways it is used. Because if you aren’t fully aware of LST’s various uses—and what constitutes LST, you may find yourself strung out on it (which is ok if you want that, but very not ok if you don’t).

What comes to mind when you hear the phrase “life support?” I’ll wager that images of ambulances and emergency rooms arise, with a medical SWAT team conducting resuscitation via chest compressions and defibrillation (electric shocks to the heart). Maybe there’s an oxygen mask over a stricken person’s face, maybe a tube placed down the trachea (intubation). In other words, the tools and methods used to literally save a life in an extreme moment.

Perhaps you’ve read about “code” calls in-hospital, when a team of resuscitators swarms a patient who’s arrested, resulting in a 30-to-60-minute long rib-cracking, groin-injecting, limbs-akimbo session.

Many people say that they do not want these interventions, and believe that saying so in writing via a living will, or in family conversations, is sufficient to protect themselves against receiving them. In next month’s article I’ll discuss the forces that lead us onto a slippery slope culminating in our traveling curative and heroic treatment paths we had previously stated we wished to avoid. For now let’s identify what that slippery slope is made of: life support technology that’s used in various ways that you may not know about (we didn’t, during my dad’s terminal hospitalization—and not knowing may have shortened his life by years).

LST, specifically intubation, is used in two ways beyond emergencies: as standard operating procedure during surgeries, and as treatment whenever providers deem it so (and we agree to that definition and to the treatment).

During surgery, core bodily processes must be managed. Pain is one, breathing another. Let’s focus on breathing because intubation is a primary aspect of ongoing, perhaps invasive use of LST. When a surgical procedure is involved enough and/or one’s condition requires, intubation to manage breathing will occur (alternative tools exist and are not always safe or appropriate). Asking doctors to perform surgery with a patient under general anesthesia and without intubation may be akin to asking them to operate with one hand tied behind their backs.

Additionally, surgical release forms may specify several things:

  • that do not resuscitate orders be overridden for the the duration of the surgery, and
  • that LST may be reinstated post-op for durations between 2 to 48 hours.

As I understand it, this is standard operating procedure. It makes sense if you’re a doctor; it may seem unreasonable if you want to receive surgical treatment but don’t want to agree to be potentially subject to full-on post-op life support measures. If you have concerns about ongoing intubation, you have something to learn about, discuss, and negotiate with your surgeon. One option is to agree, in writing, to what’s known as a Time-based Trial. This means that in the event that post-op reintubation was required, you set a time limit. It that interval runs out with you having been extubated (the tubes being removed), that extubation will occur without further negotiation or medical approval. Realize that this may be a choice to die.

Once a patient is on LST, the medical and social inclination is to continue it. Medicine inclines toward continued LST use because it defaults to life and considers dying both a professional and personal failure. To the extent records are kept and grading occurs, facilities and providers may not want people dying under their roofs and treatment. Patient-families incline toward continued LST use because we hope for a miracle and restored, undiminished life for our loved one. And, sans examination of all these issues, because once “plugged in,” pulling the plug feels like killing our loved one.

This article doesn’t discuss the ethics, morality, or fiscal aspects of LST used as treatment. What’s important for this discussion is that you recognize how LST is used every day, and that transitions between these uses are made almost reflexively. This is the centerline of the slippery slope.

Another aspect of LST is exactly what constitutes it. More mundane interventions may be, in fact or in function, LST depending upon the circumstances. For instance, the new Colorado Medical Orders for Scope of Treatment (MOST) form lists antibiotics; their inclusion defines them as a form of LST. If you’re popping a Nitro to overcome heart problems, isn’t that LST? How about an implanted pacemaker, a device which stays inside your chest until you die, cannot be user programmed, the data of which is not yet shared with the person in who it is implanted, and once implanted (“plugged in”) may prove difficult to impossible to direct doctors to turn off?

Life support technology can give options, and it can take options away. Give lots of thought to its ramifications, well in advance of finding yourself in a position where it may be deployed, taking away your freedom to choose or direct a peaceful demise.

Posted August 2012 on