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End of Life Decisions


By: the Alzheimer's Association

Honoring the wishes of the person with Alzheimer’s disease

Dementia is a general term for the loss of decision-making, memory and other mental abilities serious enough to interfere with daily life. Alzheimer’s disease, the most common form of dementia, is a physical and terminal illness. When a person with late-stage Alzheimer’s disease nears the end of life and is no longer able to make decisions, families must make choices. In ideal circumstances, the person with dementia has put advance directives into place to specifically spell out his or her wishes. Without such directives, or if certain issues were not addressed, families must make decisions based on what they believe the person would want. End-of-life decisions should respect the person’s values and wishes while maintaining comfort and dignity.

The Alzheimer’s Association can help you prepare for making end-of-life choices such as:

• Advocating for the kind of care that is based on the expressed wishes of the person with dementia

• Refusing, starting, limiting or ending medical treatments

• Making the change from treatment to care that is focused on comfort

• Arranging for a brain autopsy

Honoring the person’s wishes

Advance directives

A person with dementia has the legal right to limit, refuse or stop medical treatments. These wishes are usually expressed through advance directives – legal papers that specify the type of medical care a person wants to receive once he or she can no longer make such decisions due to incapacity. If advance directives are not in place, the family must be prepared to make decisions consistent with what they believe the person would have wanted while acting in that person’s best interest.

Types of advance directives:

Living will

A living will is a set of written instructions that provides specific preferences about the kind of medical treatment that a person would or would not want to have. A living will does not designate someone to make medical decisions on the person’s behalf. Instead, it allows the person to communicate wishes about future care.

Durable power of attorney for health care

This document allows a person to choose a partner, family member or trusted friend to make decisions about care and treatment when the person with dementia is no longer able. Advance directives should be made when the person with dementia still has legal capacity – the level of judgment and decision-making ability needed to sign official documents. These documents should be developed as soon as possible following a diagnosis of dementia. Contact the Alzheimer's Association for information about making legal plans. Use the forms for advance directives that are recognized in the state where care is, or will be, provided. Your local Alzheimer’s Association can assist you with these forms.

Take action to make sure advance directives are followed:

Give copies of advance directives to all those involved in decisions

• Family members

• Doctors

• Other health care providers Have advance directives placed in the individual’s medical record. If the person is transferred to a new setting, provide copies to those newly involved in caregiving.

Discuss advance directives

Family members should understand, respect and abide by the person’s wishes. Discuss these wishes together as a family to work out any disagreements. This helps prevent future conflict or crisis decision-making. Discuss advance directives with the doctors and other health care providers to ensure they’re aware of their patient’s wishes. If a conflict develops between members of the family or with health care providers, residential care facilities and hospitals often have ethics committees that can help.

Stay involved in medical decisions

Work with the health care team to create and follow a care plan based on the advance directives. Make sure you are kept informed of any changes in your loved one’s condition that may prompt the need for new decisions.

Understanding levels of care

Be aware of the range of medical care available when making decisions to use, withdraw, limit or refuse treatment for the person with Alzheimer’s.

Aggressive medical care

Aggressive medical care is a term used to describe measures to be taken to keep a person alive and may include:

• Respirators
• Feeding tubes
• IV hydration
• Antibiotics
• CPR Respirators

If a person with Alzheimer’s is no longer able to breathe independently, a respirator may be used to help the individual breathe. However, this treatment may cause the person’s body to undergo unneeded stress and can cause greater discomfort.

Feeding tubes

Feeding tubes are sometimes used if a person has a hard time eating or swallowing, which often happens in late-stage Alzheimer’s disease. However, there is no proof that tube feeding has any significant benefits or extends life.

Tube feeding can also result in:

• Infections
• Need for physical restraints (the person may try to pull out the tube, causing injury)

There are other ways to feed a person with late-stage Alzheimer’s, such as a carefully monitored, assisted-feeding program. For someone who can no longer swallow, an approach focusing on comfort in dying is most appropriate.

IV hydration

Liquid given to a person through a needle in a vein, IV hydration may temporarily provide fluid when a person can no longer drink, but it cannot supply the nutrition needed to stay alive. Increased hydration may also make the person less comfortable because it can cause difficulty breathing. Lack of hydration is a normal part of the dying process and allows a more comfortable death over a period of days. Using IV hydration can draw out dying for weeks and physically burden the person. If artificial nutrition and hydration are used, families will eventually need to decide if or when these treatments should be stopped.

Antibiotics

Several types of infections, such as pneumonia and urinary tract infections, are common in late-stage Alzheimer’s. Antibiotics may be prescribed to treat an infection, but they might not improve the person’s condition.

CPR

A family may have to decide whether medical professionals should try to revive a person with cardiopulmonary resuscitation (CPR). CPR is a group of treatments used to restore function when a person’s heart and/or breathing stops. It may include mouth-to-mouth breathing or pressing on the chest to mimic heart function and cause blood to circulate.

Consider that CPR:

• May be painful and traumatic

• May leave the person in worse condition

• May not prolong life

• Is not recommended by many experts when a person is terminally ill The family can ask the doctor to sign a “do not resuscitate” (DNR) order and place it in the medical chart. A DNR states that no attempts will be made to revive the person. Comfort or palliative care Instead of seeking a cure or trying to prolong life, comfort care focuses on dignity and quality of life. It aims to keep the person comfortable and pain-free until life ends naturally. Comfort care covers a variety of care options and does not mean withholding all treatments. A person can continue to receive any necessary medications, for example, for chronic conditions such as diabetes or high blood pressure, as well as those that prevent pain and discomfort. Through comfort care, the person avoids medical treatments, tests and procedures that may do more harm than good. Comfort care focuses on the quality of remaining life.

Hospice care

Hospice programs provide comfort care and preserve the dignity of those in the last stages of terminal illness while also offering support services to families. It can be provided at home or in a hospital or residential care facility. A hospice team includes a doctor, nurse, social worker, dietician, clergy and trained volunteers. They work together to address the physical, emotional and spiritual care of the person as well as the family. For Medicare to cover hospice care, a doctor must estimate that the person has six or fewer months to live. Hospice benefit may be extended if the person lives longer than expected. Your local Alzheimer’s Association can refer you to hospice services in your area.

Making informed decisions

Consider the factors below when making choices about your loved one’s end-of-life care. Follow instructions given in advance directives, if available.

Focus on the person’s wishes

Compare any recommended treatments or actions with the person’s wishes for care, or with what you believe he or she would have wanted.

For example:

• Did the person want all available treatment measures or only certain ones?

• Did the person want medication to fight pain but not infection? Stay true to their values and beliefs

Consider all factors that would influence the person’s decisions about treatments, as well as definitions of quality of life and death, like:

• Cultural background

• Spirituality

• Religious beliefs

• Family values

Be aware of the differences between your values and beliefs and those of your loved one – and make sure it is the person’s values and beliefs that are guiding your decision.

Weigh pros and cons of treatments Talk with the medical care team about the impact of using or refusing specific care treatments, for example:

• Will the treatment improve the person’s condition or comfort?

• If so, how long will the treatment benefit the person’s condition or comfort?

• Will the treatment create physical or emotional burdens? Compare any recommended treatments with your loved one’s wishes for end-of-life care. Consider where care will be given Discuss with the care team if and when moving someone to a different setting is best.

Find out if the treatment or care:

• Can be provided in familiar surroundings

• Requires transfer to another setting

Sometimes the temporary transfer to a hospital for a procedure – such as putting in a feeding tube – is disorienting and may be harmful to the person with dementia.

The difference between withholding treatment and assisted suicide

You should not think that any refusal or withdrawal of treatment – including tube feeding, antibiotics, CPR or other treatments – is considered assisted suicide (euthanasia). Limiting treatments lets the disease take its natural course and supports the person’s comfort and dignity. If treatment is refused or withdrawn, the care team will still provide good care.

Resolving family conflicts

Family members need to take part in ongoing discussions when making decisions on behalf of their loved one. Some may disagree about a recommended treatment and get angry or defensive. Or, they may refuse to engage in discussions because they feel the family is “planning for death.”

These guidelines may be helpful when dealing with family conflict:

Listen to each family member with respect Family members may have different opinions about end-of-life preferences and quality of care. And they may not fully accept that the person is approaching death. Help family members avoid blaming or attacking each other as this will only cause more hurt. Involve a third party A physician, nurse, social worker, hospital ethics committee member or spiritual leader can be asked to facilitate family meetings and help work through difficult issues.

Cope with your feelings together

The approaching death of a family member is an emotional time for everyone and may cause people to act in unusual ways. Caregivers and their families may want to seek emotional support, particularly during the last stage of the disease.

Contact the Alzheimer’s Association about support groups that can assist you and your family members in working through emotions, including:

• Stress
• Grief
• Guilt
• Anger
• Depression

Arranging for a brain autopsy A brain autopsy involves a researcher or physician to examine the brain after death to look for the plaques and tangles found in Alzheimer’s-affected brains. It is the definitive way to confirm a diagnosis of Alzheimer’s. And, it may provide information researchers can use to better understand the disease. A brain autopsy may involve cost and special arrangements. Some brain donation programs provide a free autopsy report. Make the decision before the person’s death. To learn more about getting a brain autopsy, contact the Alzheimer’s Association.

Terms you should know

Advance directives:

Legal papers that specify the type of medical care a person wants to receive once he or she can no longer make such decisions due to incapacity

Aggressive medical care:

Care and treatments that are meant to prolong life when a person is close to death

Brain autopsy:

A scientific examination of brain tissue after death that often allows doctors or researchers to confirm if a person had Alzheimer’s or another type of dementia

Comfort care:

Also known as palliative care, refers to care that emphasizes quality of life and dignity by keeping a person comfortable and pain-free until life ends naturally

CPR or cardiopulmonary resuscitation:

CPR is a group of treatments used to restore function when a person’s heart and/or breathing stop. It may include mouth-to-mouth breathing or pressing on the chest to mimic heart function and cause blood to circulate.

DNR or Do Not Resuscitate order:

Refers to a person’s instructions that, if his or her heart or breathing stops, the doctor should not try to restart it

Durable power of attorney for health care:

This document allows a person to choose a partner, family member or trusted friend to make his or her decisions about care and treatment when the person with dementia is no longer able.

Feeding tube:

A tube that provides artificial nutrition when a person is unable to eat. The most common type of feeding tube is inserted through an incision in the stomach.

Hospice care:

A type of comfort or palliative care provided at home, a hospital or a residential care facility. Hospice care is for an individual who has six or fewer months to live.

IV hydration:

Providing liquids through a needle into a person’s vein when he or she can no longer drink independently.

Legal capacity:

The level of judgment and decision-making ability needed to sign official documents

Living will:

Written instructions that provide specific preferences about the kind of medical treatment that a person would or would not want to receive.