1. Withholding/withdrawing life-sustaining therapies Suzana Makowski, MD MMM FACP

2. The EPEC-O TM Education in Palliative and End-of-life Care - Oncology Project The EPEC™-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

3. Overall message Withholding or withdrawing life-sustaining therapies is sometimes warranted, is ethical and legal in many circumstances.

4. Examples of life-sustaining therapies Resuscitation Intubation/mechanical ventillation Blood transfusions Dialysis AICD Antibiotics Artificial hydration/nutrition Hospitalization/ICU admissions Surgery Diagnostic tests

5. Let’s talk about food

6. Enteral Nutrition NG, PEG, Jtube Head & neck cancer, Neurologic injury Temporary loss of ability to eat.

7. Enteral Nutrition & Survival No effect on: Aspiration risk Pneumonia risk Symptoms. Associated with increased mortality in patients with dementia, etc.

8. Parenteral nutrition Venous access Beneficial with: long-term gi toxicity, short gut syndrome, ovarian carcinomatosis. Not beneficial in: long-term feeding for cachexia/anorexia.

9. Effects of nutrition on survival & response rates

10. Parenteral hydration IV or SQ Does not relieve dry mouth

11. Common Concerns Legally required to do everything? Is withholding or withdrawing care euthanasia? Are you (or the family) killing the patient by withholding or withdrawing nutrition, fluid, or life-sustaining treatment?

12. Steps to discuss withholding/withdrawing artificial nutrition/hydration S – set-up, background P – Preparation I – Inquiry: what are the goals? What is the understanding? What cultural beliefs? K – Knowledge: listen and share. Address misperceptions. (Not alleviate: dry mouth, decrease intake, fatigue/energy, starvation, urine output. Side effects: fluid overload, breathlessness, nausea/vomiting.) E – Emotions: wait. Acknowledge. (starvation, giving up, suffering, “not doing something”) S – Summarize/strategize

13. Cases

14. “We want to do what’s best, and what she wanted us to do…” CS is an 82 yo woman found unresponsive at home. Found to have large hemorrhagic stroke MCA, with only brainstem function remaining. PMH: HTN, high cholesterol. Exam: Respirations shallow, rapid. HR fast. Unresponsive. Brought “comfort one” form from refrigerator. Niece is HCP. Agrees DNR/DNI no ICU. What is comfort care? Pt hasn’t eating in 3 days: doesn’t she need IVFluids, blood tests, oxygen tests?

15. “I don’t want her to starve” 89 yo patient with advanced Alzheimer’s dementia (speaks only a few intelligible words, dependent on all ADLs) admitted with dyspnea, cough, mental status change found to have aspiration pneumonia. Found to have aspiration pneumonia. Failed swallow evaluation. Daughter/son knows patient doesn’t want pt to starve, but is concerned that pt can’t swallow. Additionally, nursing home might require feeding tube for readmission.

16. Thank you