Life Support Health Article

Preparation

The need for life support may arise suddenly and with little warning. All people should discuss in advance with family and doctor their wishes for the use of life support should a medical crisis develop. The doctor will note the preferences in the patient's record. Patients should sign documents such as an Advance Directive and Durable Power of Attorney for Health Care to express their wishes and designate a surrogate decision-maker in case of incapacitation.

Physicians and medical care providers must anticipate the possibility that a patient will require life support, perhaps suddenly. In preparation, doctors and medical staff must:

• receive training in resuscitation skills
• monitor patients carefully
• maintain proper supplies and equipment
• discuss in advance with patients and patients' families whether or not to begin life support

Aftercare

If a patient survives life support treatments, doctors will cautiously try to wean the patient from the support systems. Being able to breathe adequately without the ventilator is one major hurdle. Patients commonly fail in their first attempts to breathe on their own, often tiring out after a few hours. Thus, the doctor will reconnect the ventilator, give the patient a rest, and try again in a day or two.

As the patient regains organ function, there is less need for monitors, tests, and treatments that require an intensive care setting. The doctor may transfer the patient to a lower level of hospital care, a skilled nursing facility (SNF), or perhaps directly to home. Physical and occupational therapists may help the patient improve strength and endurance. The patient will receive continuing care from the primary doctor and specialists as needed. The patient may require prescription drugs, assist devices, and psychological therapists.

Risks

The risks and consequences of life support are enormous. These risks include:

• physical dangers
• emotional suffering
• financial costs
• societal discord

The physical dangers of life support encompass all the hazards of the patient's underlying disease and treatments. Among these risks are:

• permanent damage to the brain, kidneys, and other vital organs caused by poor circulation or low oxygen content of the blood
• direct damage to organs from use of medical instruments and procedures
• infections, often with organisms that are highly resistant to antibiotics
• abnormal blood clots
• skin ulcers from lying immobilized for long periods
• extreme pain
• exposure of medical personnel to communicable diseases

The emotional consequences of life support touch patients, families, and medical caregivers. These repercussions arise from:

• the frightening environment of an ICU
• the need to make life-and-death decisions
• the anger, guilt, and grief that relate to life-threatening illness
• the fact that many lengthy and difficult treatments will end in failure

The financial costs of life support are huge. A single day of life support costs many thousands of dollars. These expenses fall on individual payers, insurance companies, health plans, and governments. All such payers face difficult decisions regarding the allotment of money for such treatment, especially in cases that are likely to be futile.

Society as a whole faces difficult decisions surrounding life support. Some governments have enacted regulations that establish priorities for the spending of health care resources. Patients who do not receive treatment under such rules may feel victimized by society's choices.

BOOKS

Irwin, Richard S., Frank B. Cerra, and James M. Rippe, ed. Irwin and Rippe's Intensive Care Medicine. Philadelphia: Lippincott-Raven, 1999.

Luce, John M., "Approach to the Patient In a Critical Care Setting." In Textbook of Medicine, edited by Goldman, Lee and J. Claude Bennett. 21st ed. Vol. 1. Philadelphia: W.B. Saunders Company, 2000, pp. 483-4.

Tintinalli, Judith E., et al, ed. Emergency Medicine: a comprehensive study guide. New York: McGraw-Hill, 2000.

Isaac R. Berniker

KEY TERMS

Cardiopulmonary—Relating to the heart and lungs.

Central line—A tube placed by needle into a large, central vein of the body.

Coma—Unconsciousness.

Defibrillation—Use of an electric shock to restore a normal heartbeat.

Endotracheal tube—A tube placed into the wind-pipe through the nose or mouth.

Foley catheter—A tube that drains urine from the bladder.

Homeostasis—The internal chemical and physical balance of the body.

Nasogastric tube—A tube placed through the nose into the stomach.

Neuromuscular—Relating to nerves and muscles.

Resuscitation—Treatments to restore an adequate airway, breathing, and circulation.

Sepsis—An overwhelming infection with effects throughout the body.

Tracheotomy—A surgical procedure in which a tube is inserted into the trachea through an incision made in the base of the throat.

Trauma—Serious physical injury.

Ventilator—A machine that pumps air in and out of the lungs.

Vital signs—Basic indicators of body function, usually meaning heartbeats per minute, breaths per minute, blood pressure, body temperature, and weight.