Medical efforts to prolong the lives of individuals afflicted with serious disease or injury began with primitive medicine, perhaps in the Neolithic Period (8000-3000 B.C.), when we discerned from paleontologic evidence a tendency for primitive men and women to care for the sick and wounded in the shelters provided by the deep caves of Europe.
It was because of the medical (magical) expertise in prolonging (and sometimes saving) the life of the wounded hunter or sick mother, using herbs, rituals, magic, or by invoking friendly spirits, that the healer, the medicine man or Shaman, obtained recognition in primitive societies.
Traditional Medical Ethics and Practice
With the advent of ancient Greece and the advances in science and medicine, and the teachings of Hippocrates (460-370 B.C.), the Father of Medicine, the etiology of illness was ascribed to natural causes rather than magic, and the role of the physician became supportive, using medical knowledge to assist nature in healing the body.
The Oath of Hippocrates specifically held, “I will follow that method of treatment which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel.” Thus, the Oath forbade the practice of euthanasia (from the Greek , eu — “good” and thanatos — “death,” for mercy killing ) by Graeco-Roman physicians, followers of Hippocrates and the teachings of his school on the Island of Cos. Doctors who subscribed to the ethics of Hippocrates forswore to “first, do no harm.” It followed naturally that physicians would do their utmost to sustain life while avoiding doing harm to their patients or taking any steps to advance their deaths. From the sixth century B.C., to the Renaissance, the ethical and clinical teachings of the Greek physicians, Hippocrates and Galen (AD 130-200), were paramount.
In the seventeenth century, frantic, and herculean efforts to save the life of the great Stuart monarch, Charles II (1630-1685) were undertaken. The king most likely had suffered a cerebral embolism (stroke), which may not have been fatal. Instead, the desperate measures not only caused him agony, but likely brought about his demise. Among the treatments applied to him were repeated purgings, enemas, cupping, bleeding, and the administration of remedies used by the well-intentioned court physicians possessed only with the very scanty medical knowledge of that era.
Likewise, in the eighteenth century, George Washington (1732-1799), the Father of the United States, succumbed to his illness, most likely streptococcal pharyngitis (“strept throat”) complicated by upper respiratory obstruction — as well as to the excessive bleeding undertaken by his physicians in extraordinary attempts to cure the disease and prevent his death.
Heroic efforts at prolonging life then and now were undertaken because of the assumed ethical obligation on the part of the physician, and because, even with the advances of modern medicine, it was (and still is) sometimes very difficult to ascertain and predict, among the critically ill, who will live and who will die.
The implementation of life-prolonging measures has become a subject of debate because many persons do not die suddenly from acute illness or trauma but, instead, are afflicted with chronic illnesses that cause untold pain and suffering before the patient finally succumbs. These patients may become debilitated, lapse into coma, and become subject to prolonged medical and sometimes “futile” care. After an acute central nervous system (CNS) insult (e.g., a serious brain injury causing a traumatic mass lesion in the brain, like a blood clot, or even following complications from chronic metabolic disorders), patients may undergo alterations in the level of consciousness (LOC), lapse into stupor and coma, deteriorate into deeper stages of coma referred to as rostro-caudal deterioration. This pathophysiologic process of brain dysfunction occurs, stepwise, as if the cerebrum, “from the top,” followed by the midbrain, and finally the brainstem, “at the bottom,” were being serially sliced and their CNS functions progressively turned off. This phenomenon occurs from swelling (edema), vascular congestion and infarction (i.e., decreased circulation with vascular damage), and brain shifts (herniations) that eventually result in death from cardiopulmonary arrest.
At some point, though, this process may be interrupted either by medical therapeutic intervention, or spontaneously, with the brain adjusting to the increased intracranial pressure, and the patient survives, although in a chronic or persistent vegetative state. Generally, life-prolonging measures are instituted when physicians think recovery is possible. Some patients will go on to die despite intensive care efforts, while others languish in a persistent (or chronic) vegetative state (PVS) or remain in a deeply comatose condition.
It is at this stage that physicians must perform serial neurological examinations not only to follow the clinical course but also decide if the patient has still any chance of recovery. Evidence of significant residual brain function means possible recovery and a good prognosis. Severe, irreversible injury means no chance of full recovery and a grave prognosis. Further worsening means that brain death is imminent. It is important to note here that the patient may continue to have a heartbeat and maintain his blood pressure and circulation, despite the development of brain death because of the artificial means of medical support, such as mechanical ventilation (via respirator), which had been instituted earlier by the physician and nursing staff on an emergency basis.
This is a very difficult time for the patient’s family, and the physician must be prepared to provide support and, if necessary, spiritual and psychological counseling using ancillary personnel such as consultation with the family minister or priest, hospital chaplain, or psychological counselor. In patients whose terminal illness is cancer, hospice care may have already been instituted. This provides additional family support.
Until the nineteenth century, all that could be done for patients with chronic, debilitating illnesses was supportive nursing care or, in the case of brain injury, risky decompressive surgery with lamentable but usually rapid, predictable clinical results. With the advent of the twentieth century, intravenous (IV) therapy, providing fluids, nutrition, medication and circulatory support through a catheter placed in a vein, became commonplace. Nasogastric tubes (i.e., a flexible feeding tube inserted through the nose and ending in the stomach) to provide foods and medications become (and remain) standard medical care for the chronically ill unable to take oral nutrition.
Endotracheal intubation, tracheostomies, and mechanical ventilation via respirators, likewise, became available to maintain the patient’s breathing and to provide oxygen to the body. Respiratory therapists to assist patients on mechanical ventilation became commonplace in the modern intensive care unit (ICU). To maintain circulation and adequate blood pressure, medications such as dopamine and other vaso-constrictor agents and cardiac drugs became available and are still being used widely in the ICU setting.
With this therapeutic armamentarium, patients are maintained in the ICU while the vital functions of various organs of the body are supported. This is of utmost importance for the preservation of cerebral function, if the patient is to survive without significant brain damage. To sustain (or replace) renal function and to remove toxic chemicals produced by the body’s metabolic processes, renal dialysis became available. With different methods, such as renal and peritoneal dialysis, harmful toxic substances can be removed from the body when the kidneys no longer function properly.
Unfortunately, prolonging life does not necessarily equate to survival, nor does it assure a return to normal life, if the patient lives. As alluded to earlier, there is no assurance the patient’s life will be saved. Even if a patient’s life is temporarily sustained via cardiopulmonary resuscitation (CPR), which is used to restore breathing and/or heart beat when these functions fail, there is no assurance that the patient will survive intact or that he will not have serious neurological deficits.
Although IV therapy, feeding tubes, respirators, etc., have largely applied to the severely ill patient in the ICU, intensive medical and nursing care and life-prolonging measures can also be administered to the ambulatory patients in the hospital or home setting. Renal dialysis, for example, is routinely performed on an outpatient basis in ambulatory patients who are independent in performing activities of daily living (ADL).
It’s not surprising that chronic illness may cause patients to become depressed and sometimes feel that their lives are no longer worth living. In these cases, family, medical, and nursing support and counseling may be imperative. Counseling goes along with full, informed consent. The patient should be fully informed about the natural history of the disease, treatment options available, advantages of therapy over potential risks, and the prognosis (chances of recovery) discussed. Permission should always be obtained before treatment is instituted. The competent adult patient has a right to refuse medical care.
Most hospitals today provide information about Advance Medical Directives. Advance directives are explained by hospital or nursing personnel and may be signed by patients in anticipation of hospitalization and treatment before unpredictable medical complications or unforeseen medical conditions, such as irreversible brain damage or coma can take place. Progression of the terminal illness may occur, so that the patient later may be unable to communicate with the medical staff. Advance directives therefore can limit the therapeutic interventions that can be ordered and instituted by physicians and nursing staff before the patient worsens and is no longer able to do so.
There are two types of Advance Medical Directives: Living Wills and Durable Power of Attorney. Living Wills consist of expressly written instructions that a patient wishes to have in effect regarding his medical care in advance should his condition worsen. Likewise, with a Durable Power of Attorney the patient authorizes another person to make decisions for him when he becomes medically unable to do so.
In short, advance directives provide guidelines for a patient’s medical care when he is incapacitated and does not wish to have his life prolonged with life-supporting measures when there is little chance of recovery.
Euthanasia — The Debate
As alluded to earlier, sometimes it is difficult to predict who will live and who will die, despite appropriate medical treatment, and it becomes difficult for the physician to advise the family about discontinuing futile treatment. “Do not resuscitate” (DNR) orders are instructions written by the physician so that heroic measures are not instituted in the event that the patient has a cardiopulmonary arrest in the hospital ward or ICU. This means that the nursing staff will not intervene with resuscitative measures, such as endotracheal intubation (insertion of a breathing tube), application of mechanical ventilation, cardiac massage, or electrical defibrillation of the heart. Living Wills and advance directives assist the physician in making life and death determinations (e.g., DNR orders) with the help of the patient’s family.
However, not all physicians agree that advance directives are necessarily desirable. Dr. Jane Orient, Executive Director of the Association of American Physicians and Surgeons (AAPS) writing in her book, Your Doctor Is Not In — Healthy Skepticism About National Healthcare, questions, “ Why do we need a new elaborate, legalistic procedure? Why can’t people simply exercise their right to reject medical care, once they decide that it isn’t worth it? The fact is that they can — I think we are just afraid not enough of them will, unless we encourage that choice.” (Orient 1994, p. 166) In other words, the serious concern is that the advance directive movement is part and parcel of the “right to die” and “duty to die” movements discussed in the article Bioethics — The Life and Death Issue posted on this website — another subtle attempt at promoting utilitarian ethics and the “rational allocation of scarce and finite health care resources” for the good of society, at the expense of the chronically ill and the most vulnerable in our society.
In his book Forced Exit — The Slippery Slope From Assisted Suicide to Legalized Murder, euthanasia opponent and attorney Wesley J. Smith, points out that in 1986 the American Medical Association (AMA) paved the way to legitimize euthanasia by the withholding of water from unconscious, non-terminally ill patients when the AMA Council on Ethical and Judicial Affairs stated that “although a physician ‘should never intentionally cause death,’ it was ethical to terminate life-support treatment, even if ‘death is not imminent but a patient’s coma is beyond doubt irreversible and there are adequate safeguards to confirm the accuracy of the diagnosis and with the concurrence of those who have responsibility for the care of the patient.’ ” The Council went on to affirm that “ life-prolonging medical treatment includes medication and artificially or technologically supplied respiration, nutrition and hydration.” Smith adds, “There it was. For the first time, food and fluids provided by a feeding tube were ‘officially’ deemed a medical treatment that could be withdrawn ethically, the same as turning off a respirator or stopping kidney dialysis.” (Smith 1997, p. 45)
The famous case of Nancy Cruzan of 1987 was perhaps the most significant in establishing the “consensus” that death by dehydration was “ethical” and lawful. In this case, the courts established that the family of Nancy Cruzan — an unfortunate vegetative survivor of a 1983 automobile accident (in which she was the driver) — had the right to withdraw foods and fluids from the patient. After a series of legal battles, this was finally done and she died twelve days later in December 1990. Even Dr. Jack Kevorkian, the zealot physician assisted-suicide proponent, has been quoted as denouncing death by dehydration as inhumane.
In 1994, the AMA Council on Ethical and Judicial Affairs made another revision down the slippery slope of establishing and approving euthanasia as ethical medical practice. Smith writes, “Where once the patient had to be ‘beyond doubt’ permanently unconscious to permit withdrawing food and fluids, now even if the patient is not terminally ill or permanently unconscious, ‘it is not unethical to discontinue all means of life-sustaining medical treatment [including food and fluids] in accordance with a proper substituted judgment or best interest analysis.’ ” (JAMA 1994, p. 49-50)
Dr. Edward Annis, past president of the American Medical Association (AMA), states in his book Code Blue — Healthcare in Crisis that a physician has no right to terminate the life of a patient. Nevertheless, he asserts that withdrawing life support machinery is very different from administering euthanasia. He argues that “the current system is so geared to continuing treatment of the terminally ill — even those languishing in a persistent vegetative state — that families of patients sometimes find that they are powerless to stop the treatment.” (Annis 1993, p. 181)
That ethical attitude, though, has been evolving, and with the advent of the twenty-first century, it is no longer prevalent. As early as the 1970s and 1980s, the attitude of physicians was changing from enlightened paternalism to gatekeepers primarily concerned with over-utilization of medical services. Calls were then heard both for patient autonomy and for implementation of means to control health care costs. About this time, proponents of bioethics asserted that some patients' lives were not worth living (i.e., "quality of life" ethic) and that patients and their families had the right to terminate care — not only in cases of terminal disease and persistent vegetative states (PVS; i.e., where the patient is cognitively impaired), but even in non-terminal, chronic debilitating conditions.
No sooner had patient autonomy (i.e., respect of patient's wishes as to resuscitating measures) become an article of faith in bioethics than "ethical" conditions were then redefined. Since the 1990s the utilitarian ethic began to reign supreme, and currently in the early twenty-first century, the futile care theory prevails at least in academic circles. This theory in its essence holds that physicians and hospitals have the right to withhold treatment that they consider futile and to limit life-sustaining measures without patient consent. Futility, though, is not a medical definition but a subjective value judgment made by bioethicists in theory and by physicians in practice, practitioners inclined to the new utilitarian ethics of cost containment, and willing to render judgments about "quality of life" issues and the "proper allocation of finite resources." So much for the cherished principle of informed consent and patient autonomy!
Sooner or later, though, life ends, and an individual is pronounced dead because irreversible cessation of brain function occurs. The concept of brain death is presently accepted and utilized by the medical profession, and the legality and constitutionality of cerebral death as representing the death of an individual has been upheld in U.S. courts. Nevertheless, the establishment of cerebral (brain) death is a clinical diagnosis, the determination of which remains the responsibility of the attending physician.
Although traditionally cessation of the heartbeat and respiratory functions have been the necessary conditions for death, the availability of the aforementioned modern, life-support systems, as we have seen, has made this determination more complex and less clear cut. Nevertheless, the determination of brain death must be made in the modern setting, wherein the patient’s respiration and heartbeat have been mechanically maintained.
Brain death is diagnosed by neurological criteria, and once these criteria have been met, the patient is pronounced clinically dead. As of yet, no case of a patient properly diagnosed with cerebral death has been reported to survive despite continuation of life support measures. Brain death indeed means the death of the patient. Brain death should not be confused with patients who have sustained short (i.e., usually less than three to five minutes) episodes of “clinical death” associated with subjective “near-death” experiences. Near-death experiences, like survival, have never been documented in patients diagnosed with brain death. This subject is discussed elsewhere in this encyclopedia under the heading of “Chronic Illness.”
In establishing the diagnosis of cerebral death the following criteria should be met:
1. Total unresponsiveness to external stimuli.
2. No spontaneous respiration.
3. No brainstem reflexes elicitable so that the pupils remain fixed and unresponsive to light and oculocephalic movements are unobtainable.
4. No encephalographic (EEG) activity of brain function. Although an EEG is not usually required for the diagnosis of brain death, it is only of confirmatory value in establishing the diagnosis. An EEG, nevertheless, should be obtained in cases of potential organ donation. Electrocerebral silence is documented when there is no brain activity and a flat line is recorded in the EEG tracings.
5. Repeat assessment. Two clinical assessments should be made no sooner than six hours apart. Some states require that two licensed physicians make the determination independently. One physician makes the diagnosis and the second physician confirms it, no sooner than six hours later. Again, this may be important in patients where organ donation is being considered, and no member of the organ transplantation team should participate in establishing the diagnosis of brain death. Also to make sure that the tradition of Hippocrates of "doing no harm" is preserved in organ transplantation, physicians have adhered to the concept of the dead donor rule, that is the organs are harvested from patients who are clinically dead.
Additionally, the diagnosis of brain death should not be made in the presence of hypothermia (i.e., body temperature below 32.2 degrees centigrade); or when CNS depression has occurred in the presence of barbiturates, iatrogenically induced (i.e., as in medical treatment) or as in cases of drug overdose.
And, the diagnosis of brain death in infants and young children is more difficult and requires longer periods of observations.
1. American Medical Association Council on Ethical and Judicial Affairs, “Opinion 2.15,” 1986; See also American Medical Association Council on Scientific Affairs and Council on Ethical and Judicial Affairs. Council report: Persistent vegetative state and the decision to withdraw or withhold life support. JAMA 1990;263(3):426-430.
2. American Medical Association Council on Ethical and Judicial Affairs. Council report: Decisions near the end of life. JAMA 1992;267(16):2229-2233; See also American Medical Association Council on Ethical and Judicial Affairs, “Opinion 2.20,” 1994.
3. Annis, Edward R. Code Blue—Healthcare in Crisis. Washington, DC, Regnery Publishing, 1993, pp. 179-184.
4. Arnett, Jerome C. Jr., and Faria, Miguel A. Jr. The ‘Tavistock principles’ of medical ethics — symposium. Medical Sentinel 2001;6(2):63-64.
5. Byock, Ira. Dying Well: The Prospect for Growth at the End of Life. New York, NY, Riverhead Books, 1997.
6. Carton, Robert W. The road to euthanasia. JAMA 1990;263(16):2221.
7. Cruzan v. Harmon and Lampkins, Case No. CV384-9p, Circuit Court of Jasper County, Missouri, transcript for March 9, 1988; Nancy Beth Cruzan v. Robert Harmon et al., 760 SW 2nd 408, Nov. 1988; Cruzan v. Director, Missouri Department of Health, 110 Supreme Court, 2841, 1990.
8. Faria, Miguel A. Jr. Vandals at the Gates of Medicine: Historic Perspectives on the Battle Over Health Care Reform. Macon, GA, Hacienda Publishing, Inc., 1995, pp. 3-7, 169-176, 255-263.
9. Faria, Miguel A. Jr. Slouching towards a duty to die. Medical Sentinel 1999;4(6):208-210.
10. Gaylin, Willard, Kass, Leon R., Pellegrino, Edmund D., Siegler, Mark. Doctors must not kill. JAMA1988;259(14):2139-2140.
11. Hendin, Herbert. Seduced by Death: Doctors, Patients and the Dutch Cure. New York, NY, W.W. Norton, 1997.
12. Humphry, Derek. Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. Eugene, OR, The Hemlock Society, 1991.
13. Lipton, Robert L. The Nazi Doctors: Medical Killing and the Psychology of Genocide. New York, NY, Basic Books, 1986.
14. Neuhaus, Richard J. The return of eugenics. Commentary, April 1988, p. 19.
15. Orient, Jane M. Your Doctor Is Not In — Healthy Skepticism About National Healthcare. Macon, GA, Hacienda Publishing, Inc., 1994, pp. 161-172.
16. Payne, Franklin E. Jr. Biblical Healing for Modern Medicine — Choosing Life and Health or … Disease and Death. Augusta, GA, Covenant Books, 1993.
17. Plum, Fred and Posner, Jerome B. Diagnosis of Stupor and Coma. 2nd edition. Philadelphia, PA, F. A. Davis Company, 1975.
18. Smith, Wesley J. Forced Exit — The Slippery Slope From Assisted Suicide to Legalized Murder. New York, NY, Random House, 1997.
19. Smith, Wesley J. Culture of Death — The Assault on Medical Ethics in America. San Francisco, CA, Encounter Books, 2000.
20. Walker, A. Earl. Cerebral Death. 3rd edition. Baltimore, MD, Urban and Schwarzenberg, 1985.
1. For information “that supports the efforts to effectively communicate a Christian perspective on bioethical issues to today’s pluralistic world”:
The Center for Bioethics and Human Dignity, 2065 Half Day Road, Bannockburn, IL 60015, (847) 317-8180, http://www.cbhd.org
2. For information about euthanasia from an opposing standpoint:
International Anti-Euthanasia Task Force, 328 N 5th St, Steubenville, OH 43952, (740) 282-3810
United States Conference of Catholic Bishops, 3211 Fourth Street N.E., Washington, DC 20017, 202-541-3000, http://usccb.org
Not Dead Yet, 497 State Street, Rochester, NY 14608, (585) 697-1640, http://www.notdeadyet.org
Written by Dr. Miguel A. Faria
This article was written in 2002 but was edited and published exclusively for HaciendaPublishing.com on October 29, 2012. The article can be cited as: Faria MA. Life-prolonging measures. HaciendaPublishing.com, October 29, 2012. Available from: http://www.haciendapub.com/randomnotes/life-prolonging-measures
Copyright ©2002 Miguel A. Faria, Jr., M.D.