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Okay, here's an unpleasant subject. End of life.

We often say "life or death" as if it's a choice. But it's not! It's a given: none of us are going to get out of here alive. But we avoid the subject. It's very difficult to talk about disease, about suffering and about death truthfully.

Here are some of my own perspectives on this subject:

We all have to go. To a certain extent, we do have the power to choose some of the circumstances of our going. Yeah, healthy habits, and all that. but what I'm talking about is a living will and a durable power of attorney for health care.

I'm not talking about signing over your assets to some conservator, here. What I'm talking about is having a very frank talk with your family, your loved ones, and telling them exactly what you would want them to decide for you if you're ever in the position of not being able to decide for yourself.

Here are my thoughts on "life support."

Sometimes a person suffers a catastrophic injury or illness. He is incapable of breathing, swallowing, moving for himself. But if he can stay alive in the mean time, the chances are good that he will heal enough to take those functions back and live normally. It would be stupid not to put this person on the ventilator, to put a feeding tube into his stomach to give him nutrition so he has enough energy to fight his way back to his own life.

On the other hand, there are illnesses and injuries that are not compatible with life. No matter what we do, this person is going to die. There are also illnesses and injuries that will allow the person to live with a great deal of artificial life support, but the person will never be in control of his body or his life. I think that feeding tubes and ventilators are inappropriate in these cases. I think that it is wrong to prolong death, when recovery is not reasonably anticipated.

This is just my opinion. I know that reasonable people have other opinions. But the important thing is that your family know what your opinion is. Even if you have a living will, if your family can't live with what you've put down, then the chances are that their wishes will be carried out, instead of your own.

So think about it. There are consequences to beginning and ending any particular type of support. A foley catheter can sometimes cause irritation to the urethra and to the bladder itself. But to take a catheter away from someone who has no bladder control sets him up for skin breakdown.

A feeding tube doesn't sound like a very invasive procedure. There are two types of feeding tubes that are inserted through the nose and sunk into the bottom of the stomach to introduce liquid tube feed formulas. This isn't considered invasive, but the tube is uncomforable to have inserted, it can cause gagging and coughing. For a DobHoff tube, the placement has to be confirmed by x-ray. The tube has must be taped to the person's nose, and the entire construct appears to be uncomfortable and itchy. A person with the feeding tube in the nose often has to have his hands restrained to keep him from pulling the tube out. This makes it much harder to rest.

I personally have a big problem restraining the hands of an disabled/elderly/dying person. I would much prefer that these people be as comfortable as humanly possible.

Another type of feeding tube is a PEG (percutaneous endoscopic gastrostomy) tube. This is inserted through the stomach wall. This is an invasive procedure, but if I was in the position to need tube feedings, I would want to have a PEG tube, no matter how short a time I'd need to be tube-fed.

Often if we have a patient with a DobHoff tube, the patient is wild as a bug, pulling his or her IV line, trying to pull the DobHoff, pulling at the foley and trying to climb out of bed, or flinging his legs over the side of the bed. Once that person has the DobHoff removed and a PEG tube inserted, all of the agitated behavior stops. Then we can take the restraints off, and the patient rests well.

Tube feedings, like everything else, have good and bad consequences. Almost everyone on tube feedings has diarrhea. If you're needing tube feeds to keep you alive and strong enough to get better, than the diarrhea is a small problem to be worked around.

But say you're old, debilitated, living the last days of your life. You're lying in a hospital or nursing home bed, and being tube fed, prolonging the decline. The diarrhea is a big problem for this persion, too. The older person's skin is less able to handle the irritation from the feces, and the repeated handling of having to be cleaned up. It's not the way I want to spend my last days.

What about CPR?

I am all for CPR in many cases. When I was in nursing school, one of my classmates suffered a lethal arrhythmia and collapsed in class (it was a killer test). We were able to keep him alive and his brain intact through CPR until the ambulance got there to deliver the defibrillator shocks. He's a nurse today!

But I think that doing CPR on an elderly person, especially when the person is in poor health is usually futile. Again - this is my opinion. If I'm called to the code of an 83 year old man who is frail and has had a stroke, I'll do my very best. But I've seen it more than once. The person will survive the code, only to succumb hours or days later.

My point is that everybody who lives has to die. I accept that. If a person has had a long life, and is now in failing health, what is the benefit to him to bring him back from a cardiac arrest? He's sick enough to stop his heart now. He's not going to come back from the cardiac arrest more healthy than he went into it!

Just think about it. Talk about it with your family. Talk about it with your doctor. Talk about it with your priest or spiritual advisor person.

That's my suggestion.

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