05 Jun Life-Sustaining Treatments (LSTs)- The Big Three: Intro
Life-Sustaining Treatments (LSTs): Benefits and Burdens
John Jones was 58 when he got the diagnosis: amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease. It started with a fall in a parking lot. It was daytime and the pavement wasn’t uneven. He told the emergency room doc that he just “tripped over my own two feet.” It took 17 stitches to close the cut on his forehead and he was told to see his doctor to have them taken out in a week. During the follow up visit his doctor noticed some abnormal muscle movements and she referred him to a neurologist, who gave him the news.
ALS is an incurable neurologic disease, that causes weakness not only in the muscles of the arms and legs but also in the muscles that control speech, swallowing, and breathing and although its rate of advancement is variable, progressive muscle weakness and paralysis is inevitable.
What mattered most to Mr. Jones was being as independent and active as possible. He was sure that if he could not walk or talk, he did not want any life-sustaining treatments. He said, “No tubes and no machines,” and completed a living will documenting this.
Now he was back in the hospital again with another bout of pneumonia. Palliative care was consulted to help him and his healthcare team to manage shortness of breath. Ultimately Mr. Jones chose a trial of mechanical ventilation. Over the next 2 weeks it became clear that he was going to be dependent on a ventilator for the rest of his life. I asked him if he had thought about how long he would want to live with his current limitations. He said he was not sure but “I’ll know when it’s time to stop.” A week later when I came into his room he motioned for the pen and paper on the bedside table. I gave it to him, and he wrote, “It’s time.”
Without question, the practice of medicine has seen the development of life-altering advances over the past 50 years. For people whose illness cannot be cured or whose independence cannot be restored, this progress presents a dilemma. The challenge is to define the line where the burdens and benefits of medical treatment must be considered. There may come a point where more treatment is not necessarily better treatment.
Life-sustaining treatments (LSTs) are medical interventions that are used when a person’s body can no longer perform essential physiologic functions. The top 3 LSTs are CPR, mechanical ventilation, and feeding tubes. Additional examples include antibiotics, transfusions, left ventricular assist devices, and dialysis.
All of these treatments have one thing in common: none reverse the medical condition causing the problem. LSTs in and of themselves do not cure diseases. They merely support bodily function while a person recovers from injury, illness, or surgery.
LSTs may or may not help someone live longer. Whether or not intensive interventions are likely to work depends on the cause and severity of the underlying medical problems. When the problem is curable, LSTs are more likely to be effective in restoring someone to their prior state of health. Sometimes LSTs are used for a short period of time to get a person through a health crisis, while people with certain conditions that won’t get better live for a long time on life support.
What further complicates the situation is that there is not a lot of information in medicine about when NOT to use LSTs, and the default is to “do everything.” Also, different people want different things: some people would want LSTs and others would not, and still some others might want one LST but not others, and preferences may change over time, as they did for my patient.
LSTs certainly hold the potential for extending survival, there is often a trade-off of loss of independence and freedom.
This series of articles discusses the benefits and burdens of the three most common LST’s CPR, mechanical ventilation, and feeding tubes.