Decisions about Life-Sustaining Treatments in the Last Days of Life
Key Points for This Section
- In the last days of life, patients and family members are faced with making decisions about treatments to keep the patient alive.
- Choices about care and treatment at the end of life should be made while the patient is able to make them.
- Care that supports a patient's spiritual health may improve quality of life.
- Nutrition Support
In the last days of life, patients and family members are faced with making decisions about treatments to keep the patient alive.
Decisions about whether to use life-sustaining treatments that may extend life in the final weeks or days cause a great deal of confusion and anxiety. Some of these treatments are ventilator use, parenteral nutrition, and dialysis.
Patients may be guided by their oncologist, but have the right to make their own choices about life-sustaining treatments. The following are some of the questions to discuss:
- What are the patient’s goals of care?
- How would the possible benefits of life-sustaining treatments help reach the patient's goals of care, and how likely would this be?
- How would the possible harms of life-sustaining treatments affect the patient's goals of care? Is the possible benefit worth the possible harm?
- Besides possible benefits and harms of life-sustaining treatments, what else can affect the decision?
- Are there other professionals, such as a chaplain or medical ethicist, who could help the patient or family decide about life-sustaining treatments?
Choices about care and treatment at the end of life should be made while the patient is able to make them.
A patient may wish to receive all possible treatments, only some treatments, or no treatment at all in the last days of life. These decisions may be written down ahead of time in an advance directive, such as a living will. Advance directive is the general term for different types of legal documents that describe the treatment or care a patient wishes to receive or not receive when he or she is no longer able to speak their wishes.
Studies have shown that cancer patients who have end-of-life discussions with their doctors choose to have fewer procedures, such as resuscitation or the use of a ventilator. They are also less likely to be in intensive care, and the cost of their healthcare is lower during their final week of life. Reports from their caregivers show that these patients live as long as patients who choose to have more procedures and that they have a better quality of life in their last days.
See the PDQ summary on Planning the Transition to End-of-Life Care in Advanced Cancer for more information.
Care that supports a patient's spiritual health may improve quality of life.
A spiritual assessment is a method or tool used by doctors to understand the role that religious and spiritual beliefs have in the patient's life. This may help the doctor understand how these beliefs affect the way the patient copes with cancer and makes decisions about cancer treatment.
Serious illnesses like cancer may cause patients or family caregivers to have doubts about their beliefs or religious values and cause spiritual distress. Some studies show that patients with cancer may feel anger at God or may have a loss of faith after being diagnosed. Other patients may have feelings of spiritual distress when coping with cancer. Spiritual distress may affect end-of-life decisions and increase depression.
Doctors and nurses, together with social workers and psychologists, may be able to offer care that supports a patient's spiritual health. They may encourage patients to meet with their spiritual or religious leaders or join a spiritual support group. This may improve patients' quality of life and ability to cope. When patients with advanced cancer receive spiritual support from the medical team, they are more likely to choose hospice care and less aggressive treatment at the end of life.
See the PDQ summary on Spirituality in Cancer Care for more information.
The goals of giving fluids at the end of life should be discussed by patient, family, and doctors.
Decisions about giving fluids should be based on the patient's goals of care. Giving fluids has not been shown to help patients live longer or to improve quality of life. However, the harms are minor and the family may feel there are benefits if the patient is less fatigued and more alert.
The family may also be able to give the patient sips of water or ice chips, or swab the mouth and lips to keep them moist.
The goals of nutrition support for patients in the last days of life are different from the goals during cancer treatment.
Nutrition support can improve health and boost healing during cancer treatment. The goals of nutrition therapy for patients during the last days of life are different from the goals for patients in active cancer treatment and recovery. In the final days of life, patients often lose the desire to eat or drink and may not want food or fluids that are offered to them. Also, procedures used to put in feeding tubes may be hard on a patient.
Making plans for nutrition support in the last days is helpful.
The goal of end-of-life care is to prevent suffering and relieve symptoms. If nutrition support causes the patient more discomfort than help, then nutrition support near the end of life may be stopped. The needs and best interests of each patient guide the decision to give nutrition support. When decisions and plans about nutrition support are made by the patient, doctors and family members can be sure they are doing what the patient wants.
Two types of nutrition support are commonly used.
If the patient cannot swallow, two types of nutrition support are commonly used:
Each type of nutrition support has benefits and risks. See the PDQ summary on Nutrition in Cancer Care for more information.
The benefits of using antibiotics in the last days of life are unclear.
The use of antibiotics and other treatments for infection is common in patients in the last days of life, but it is hard to tell how well they work. It is also hard to tell if there are any benefits of using antibiotics at the end of life.
Overall, doctors want to make the patient comfortable in the last days of life rather than give treatments that may not help them live longer.
The decision to use blood transfusions in advanced cancer depends on goals of care and other factors.
Many patients with advanced cancer have anemia. Patients with advanced blood cancers may have thrombocytopenia (a condition in which there is a lower-than-normal number of platelets in the blood). Deciding whether to use blood transfusions for these conditions is based on the following:
- Goals of care.
- How long the patient is expected to live.
- The benefits and risks of the transfusion.
The decision is hard to make since patients usually need to receive transfusions in a medical setting rather than at home.
Many patients are used to receiving blood transfusions during active treatment or supportive care, and may want to continue transfusions to feel better. However, studies have not shown that transfusions are safe and effective at the end of life.
Patients should decide whether or not they want cardiopulmonary resuscitation (CPR).
An important decision for the patient to make is whether to have cardiopulmonary resuscitation (CPR) (trying to restart the heart and breathing when it stops). It is best if patients talk with their family, doctors, and caregivers about their wishes for CPR as early as possible (for example, when being admitted to the hospital or when active cancer treatment is stopped). A do-not-resuscitate (DNR) order is written by a doctor to tell other health professionals not to perform CPR at the moment of death, so that the natural process of dying occurs. If the patient wishes, he or she can ask the doctor to write a DNR order. The patient can ask that the DNR order be changed or removed at any time.