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How does the doctor know how long someone has to live?
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That is a very difficult question. Even doctors cannot perfectly predict the future. Doctors primarily use information about the usual course of specific diseases. Research on specific diseases such as lung cancer or Alzheimer's have generated guidelines, statistics and survival curves that define an average range of possibilities for a population of people with that disease. These guidelines cannot predict the behavior of a specific disease in any one individual person. Since each person is a complex blend of medical strengths and weaknesses (as well as social and psychological factors which influence outcome), doctors must use clinical judgment together with statistics to give their best effort at a prognosis, or forecast, of the probable life expectancy. This prognosis will most likely be adjusted over the course of the disease, and will change as symptoms and signs of the disease either progress or stabilize.
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What is dementia and can you die from it?
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Dementia is a brain disease wherein a patient generally has a decline in thinking ability with a decline in the ability to function in society secondary to the mental deterioration. There are many causes of dementia; the most common cause is Alzheimer's disease, but strokes, Parkinson's disease, alcoholism, AIDS and many other illnesses can cause dementia. Dementia is one of the leading causes of death in the United States. Infections are very common in these patients and many patients with dementia die as a result of those infections.
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What is delirium and how is it different from dementia?
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Delirium is a frequent symptom at the end of life. It is a rather sudden change in mental status that occurs when the patient has a physical illness that interferes with the usual functional ability of the brain. For example, a patient who has a high fever or a severe pneumonia, or adverse reaction to a drug may become delirious. This would show itself as a new onset of confusion and disorientation, possibly hallucinations and disrupted sleep cycles all of which could get variably better and worse over the course of hours or days. In contrast, dementia is a disease that usually progresses over months to years, and affects memory and judgment more than level of wakefulness. Delirium can often be reversible if the underlying condition is treated.
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My mother has Alzheimer's disease. Can she still make decisions about end-of-life care?
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Alzheimer's disease is a deterioration of brain function that affects memory as well as other brain functions such as personality, judgment or use of language. The diagnosis of Alzheimer's disease itself should not be an absolute barrier to participation in end-of-life decision-making. Many patients with early Alzheimer's disease are still able to express their wishes in a consistent way even though their short-term memory loss may impair their ability to remember the discussion even a short time later. Because more severe Alzheimer's disease may interfere with communication, discussions and documentation of Advance Directives should take place as early in the disease process as possible.
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What is CPR?
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Cardiopulmonary resuscitation is a method of pumping blood to the brain when a patient's heart has stopped (cardiopulmonary arrest). The rescue team will use their palms to push on the patient's breastbone to compress the heart and pump the blood. Another rescue worker will force air into the lungs of the patient by blowing into their mouth.
CPR is designed to maintain brain blood flow for a short time during which the rescue team tries to stabilize the cause of the cardiopulmonary arrest. It works best when the underlying cause is correctable or treatable, for example an abnormal heart rhythm from a small heart attack or a sudden inability to breathe from drowning or choking.
It is very important that CPR be done as soon as possible when someone has a cardiopulmonary arrest. The sooner it is done, the higher the chances are that a patient will survive. CPR is not a treatment or a cure for chronic terminal illness.
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What are the other things they do during resuscitation?
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In addition to basic CPR, paramedics or healthcare workers will also insert tubes into the patients' veins to give fluids and medications. Electric shocks to the chest will be tried to return the heart to a normal rhythm. If necessary, a tube will be inserted into the windpipe, which will be attached to a machine that mechanically breathes for the patient.
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What are the risks and benefits of resuscitation?
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CPR and other resuscitative efforts can buy time when there is a reasonable hope to treat the underlying condition. CPR has saved many lives. Like any medical procedure, there are risks as well as benefits. Chest compressions can be traumatic and cause broken bones or punctured or bruised organs. Attempts at inserting tubes into the veins and windpipe can cause bleeding and injury to those or adjacent structures. There are many possible complications. One serious risk is that an adequate amount of oxygen may not be delivered to the brain, heart or other important organs, but a person may survive. This would result in a person surviving with less physical or mental function than before the cardiopulmonary arrest.
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What is intubation and mechanical ventilation? Does it hurt?
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Intubation is the process of inserting a tube into the patient's windpipe, usually through the mouth or nose, or through a surgical hole made in the neck (tracheostomy). If a patient cannot effectively breathe on their own, this tube is connected to a mechanical ventilator, which is a special pump that rhythmically pushes air and extra oxygen into the patient's lungs. Generally, a patient on a ventilator will not be able to speak, but if they are awake, they may communicate by facial expression or writing. Some patients tolerate the machine well, but many times patients on ventilators will require medication to keep them calm or sleepy since it can be stressful or uncomfortable.
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What is meant by artificial nutrition and hydration?
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Artificial nutrition and hydration can be used if a patient is unable to eat by mouth. These are medical interventions whereby a tube can be inserted into the stomach or first part of the intestines to deliver liquid food, water and medications. One type of tube is passed through the nose and down the esophagus into the stomach (nasogastric tube). These tubes can be helpful for short term feeding, but are not always well tolerated by patients long term because of discomfort or interference with normal human interactions. For longer term tube feeding, doctors can surgically insert tubes directly through the skin of the belly into the stomach in an attempt to supply enough nutrition to sustain the patient. There are also ways of delivering nutrition directly to the blood stream for limited periods or time (parenteral nutrition). This method is only used when the patient's own intestines do not work as it carries the highest rate of complications and risks.
Artificial hydration is the process of giving water or other fluids to the patient who cannot take them by mouth. In addition to tube feedings, fluids can by given by vein through an intravenous line (I.V.).
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What is the difference between an Advance Directive and D.N.R.?
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"D.N.R.", "Do not resuscitate", "No code", and "No CPR" orders are ways of saying the same thing. These are physicians' orders that instruct healthcare workers that in the event of a cardiac or respiratory arrest, cardiopulmonary resuscitation (CPR) should not be attempted.
Some people wrongly assume that having an Advance Directive automatically means "DNR". Advance Directives generally stipulate certain conditions that must be met before a DNR order is written. Patients may have a written Advance Directive for many years before any of those conditions are met. It is up to the physician together with the patient and surrogate to decide if and when a DNR order will be instituted.
If a patient has a cardiac arrest in the hospital, CPR will automatically be started unless the physician has written a DNR order. In the community, paramedics are required to initiate resuscitation efforts for cardiac or respiratory arrest unless comfort-care-only orders are written. These orders allow terminally ill patients in the community to elect to have comfort care measures only if their physician documents a written comfort-care-only order and prescribes a comfort-care-only bracelet or necklace.
It is important to remember that "no CPR" is not the same thing as "no treatment". When "curing" is no longer possible, medical treatment can focus on "caring". End-of-life care should form a continuum with the care that was received during the non-terminal stages of illness.
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