Issues to Consider When Completing Advance Directives

Cardiopulmonary Resuscitation (CPR)

Cardiopulmonary resuscitation (CPR) is a combination of rescue breathing and chest compressions delivered to victims thought to be in cardiac arrest. When cardiac arrest occurs, the heart stops pumping blood. CPR can support a small amount of blood flow to the heart and brain to “buy time” until normal heart function is restored. Statistics show that fewer than 30% of those who receive CPR survive if the procedure is begun within four minutes after the heart stops. If begun after four minutes, the survival rate drops to 7%.

CPR has the following associated risks:

  • A frail victim’s ribs could be broken and a lung punctured because of the necessary force applied during CPR.
  • If too much time has elapsed since the victim has been without oxygen, brain damage can occur.
  • The chain of events put into motion through the initiation of CPR, could cause someone to be placed on a respirator even though they might not have wanted it.
  • A terminally ill individual has virtually no chance of surviving a cardiac arrest.

In health care facilities, it is generally assumed that every patient will receive CPR if the person’s heart stops. Therefore, a DNR order must be issued by the physician if this is not what the patient would want to occur.

Mechanical Respiration (Ventilation)

Sometimes after CPR is initiated, the heart may start beating but breathing may not resume. This is known as respiratory failure. If this occurs, a machine called a respirator or ventilator can take over breathing if the lungs cannot function adequately, providing oxygen through a tube inserted in the windpipe. This is known as mechanical respiration (ventilation).

Sometimes respirators can pull a person through a serious illness from which they are expected to recover. However; in some cases, especially in the seriously ill, breathing may never be fully restored and the person becomes permanently dependent on the respirator.

There are effective medical interventions (oxygen, muscle relaxants, narcotics) that can ease distressing symptoms if a person does not want to be placed on a respirator or if they or their family want them removed from a respirator.

Artificial Feeding & Hydration

When a patient can no longer take food or fluid by mouth, feeding tubes and intravenous lines can be used to provide artificial nutrition and hydration.

Artificial hydration is when intravenous lines are used to provide fluids (hydration). This is only a temporary measure, and is not meant to be a long-term solution. The risks associated with artificial hydration include:

  • For patients without permanent venous access, the repeated placement of intravenous may be difficult and painful due to the fragility of their veins.
  • The patient may develop edema (when the body tissue retains fluid) because their body cannot tolerate the extra fluids.
  • The patient may develop respiratory distress or cardiac overload when their heart is unable to circulate the excess fluid around their body.

Artificial Feeding is done through feeding tubes, which come in two types:

1. A nasogastic tube (NG) is inserted through the nose, down the esophagus and into the stomach. This tube is not meant to be used for longer than 30 days. Risks include:

  • Discomfort for the patient, as a result of the presence of the tube.
  • Pneumonia can develop if regurgitated fluid enters the lungs.

2. A gastrostomy tube is inserted surgically through the skin into the stomach wall. Liquid nutritional supplements, water and medications can be poured or pumped into the tube. Risks include:

  • Patient may need to be restrained so they do not pull the tube out.
  • Ulcers around the site of the tube and infections can develop.
  • A patient’s body may not be able to tolerate the feedings and the feedings are regurgitated through the tube.

Patient’s with either type of feeding tube will require special care from a family member or other caregiver to administer the feedings and manage the care of the feeding tube. Depending upon the individual situation, the placement of these tubes may necessitate the individual being placed in an institution because there is no one available to provide the care in a home setting. Prior to placement of the tube, thought should be given as to how the patient’s care needs will be addressed after the tube is placed.

Many consider the use of artificial tubes to be an extraordinary measure. They argue that this is equivalent to force feeding and is more of a burden than a benefit to those people who are seriously ill or in an irreversible coma. For those individuals with a serious illness, the placement of a feeding tube will not stop the progression of the illness. Some people are concerned that if artificial feeding or hydration is not provided, it is equivalent to starving someone to death.

Others see the inability to take food and water by mouth as a terminal medical condition. They believe that withholding or withdrawing artificial feeding and/or hydration is to allow a natural death to occur and thus not prolonging the dying process.


Antibiotics are medications used to fight infections. Antibiotics can provide comfort if the infection itself causes discomfort to a conscious patient but they do not always prevent death due to serious infection. Other facts to consider with the use of antibiotics include:

  • Infections sometimes clear up even if antibiotics are not given.
  • Fever and other symptoms of infection can often be treated without antibiotics.
  • Allergic reactions, diarrhea and kidney failure can occur from the use of antibiotics.

In the seriously ill, infection may be the precipitating factor that leads to death, i.e. pneumonia in a person who has lung cancer. Serious infection in the seriously ill can lead to sleep or coma and may be the body’s way of producing a peaceful death. Some believe that treating an infection with antibiotics may only serve to prolong death.


Dialysis is the use of a machine to cleanse the blood of toxins when the kidneys cannot function adequately. The procedure takes several hours and is usually performed several times a week. Many people with chronic kidney failure undergo regular dialysis for years and tolerate the procedure well. However, dialysis has the following associated risks:

  • Dialysis can be very uncomfortable for the patient.
  • Total kidney failure can eventually produce cardiac failure or coma.

When kidney failure is combined with, or is the result of, another serious illness, dialysis does not improve the underlying condition. Some believe it only prolongs death.

Diagnostic Tests

You may wish to state in your advance directives that if you were seriously ill, you would want to refuse all but the simplest tests or any testing that would not change the treatment you would receive to keep you comfortable.

Comfort Care

Comfort care is any kind of treatment that increases a person’s physical or emotional comfort. It generally does not involve advanced technology. It can include oxygen, food and fluids by mouth, turning and positioning, and medications to relieve distressing symptoms. Many people state in their living will or health care proxy, that they want any medication that will reduce or eliminate their suffering even if it has the unintended consequence of hastening their death.