Living Will (1): Cardiopulmonary Resuscitation
A Living Will is a document in which a person expresses in advance what kinds of medical treatment they would or would not want if they later become unable to make medical decisions for themselves due to unconsciousness or other reasons.
It is also one way of thinking about what kind of medical care one would want at the final stage of life.
What to Consider in a Living Will
When thinking about a Living Will, there are two opposite approaches:
- wishing for as natural a course as possible
- wanting every possible treatment to prolong life
Of course, many people choose something in between.
For example:
- wanting chest compressions but not mechanical ventilation
- wishing to receive aggressive treatment only if recovery is considered likely
These decisions may vary depending on the situation.
The First Thing to Consider: CPR
These decisions often become necessary when the heart or breathing is about to stop.
Therefore, one of the first things to consider is cardiopulmonary resuscitation (CPR).
CPR mainly includes:
- chest compressions
- endotracheal intubation
- use of a mechanical ventilator
These procedures are performed to maintain breathing and blood circulation while treatment is provided for the underlying illness or condition.
However, even if CPR is performed, not all patients recover.
The likelihood of recovery varies greatly depending on factors such as age, underlying medical conditions, and the cause of cardiac arrest.
About Chest Compressions
Chest compressions maintain blood circulation by strongly pressing on the chest.
During the procedure, the ribs or breastbone may sometimes fracture.
This is especially common in older adults, whose bones may already be fragile.
In rare cases, broken bones may also injure organs such as the lungs.
About Endotracheal Intubation and Mechanical Ventilation
Endotracheal intubation is performed to secure an airway to the lungs.
Because a tube is inserted through the mouth into the trachea, the procedure can cause significant discomfort and distress.
For this reason, sedatives or anesthesia are often used.
In addition, because the tube passes through the vocal cords, patients are usually unable to speak while intubated.
After intubation, a mechanical ventilator is used to assist breathing.
Mechanical Ventilators and Treatment Decisions
When a patient is placed on a mechanical ventilator, communication with the patient may remain difficult for a prolonged period.
In addition, deciding whether to discontinue mechanical ventilation requires careful consideration from medical, ethical, and legal perspectives.
In Japan, guidelines and discussions regarding end-of-life care are gradually becoming more established.
However, discontinuing a ventilator may still be interpreted as an act leading to the patient’s death, and in some situations there are concerns that it could potentially become a legal issue.
In fact, there have been cases in which end-of-life medical care became the subject of criminal investigations.
As a result, healthcare providers often must approach the discontinuation of mechanical ventilation very cautiously, and withdrawing ventilation after it has been started can involve considerable psychological and ethical burden.
In practice, these decisions are considered based on the patient’s wishes, the family’s views, the medical condition, and the judgment of the healthcare team.
For that reason, it is meaningful to think in advance about how much treatment one would want.
Thinking About a Living Will
Modern medicine has advanced greatly, and many treatments can now sustain life.
At the same time, some treatments involve significant discomfort and physical burden.
In some situations, medical treatment may prolong life even when recovery is unlikely.
When people are fully conscious and able to communicate with healthcare professionals and family members, they can make their own treatment decisions.
However, there are situations in which there is little time to discuss these matters.
For that reason, it may be worthwhile to think in advance about:
“How far would I want medical treatment to go?”
In the next article, we will discuss “nutritional support and feeding.”
For general information about Living Wills in Japan, please refer to the Japan Society for Dying with Dignity.
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