End-of-life Care

Brain Death

With brain death, death is determined based on clear evidence that specific neurological criteria have been met, demonstrating that the patient has lost all brain function (including involuntary brain activity that sustains life). Brain death is not interchangeable with or the same as persistent vegetative state or coma. 


Cardiopulmonary  Resuscitation (CPR) 

A cardiopulmonary arrest is the abrupt cessation of normal circulation of the blood due to failure of the heart to contract effectively during systole.  Patients in cardiopulmonary arrest do not have enough circulation to maintain blood flow to the brain.  Irreversible brain damage and death will usually occur within a few minutes of the onset of cardiopulmonary arrest. A set of defined protocols/techniques designed to restore circulation and respiration in the event of acute cardiopulmonary arrest.  The defined protocols/techniques include closed-chest compression, intubation with assisted ventilation, electroconversion of arrhythmias, and the use of cardiotonic and vasopressive drugs.  CPR is an indicated intervention to reverse the effects of cardiopulmonary arrest.  CPR is indicated or continued when a clinical judgment is made that the defined protocols/techniques are unlikely to do so. 


Comfort Measures Only

The patient receives only therapeutic treatments that are intended/expected to optimize the patient’s comfort.  In the event of cardiopulmonary arrest, cardiopulmonary resuscitative measures or endotracheal intubation and mechanical ventilation are not initiated. 


Euthanasia (and Medically Assisted Dying) 

Latin meaning is ‘a good death’ or ‘to die well’.  Direct/intentional action taken to end a patient’s life.  Euthanasia is passive when the action is to withhold or withdraw life-sustaining technologies.  Euthanasia is voluntary when the action to end a patient’s life is taken at the request of a patient with decisional capacity.  Euthanasia is non-voluntary when the patient has made no such request.  Euthanasia is involuntary when the action to end a patient’s life is taken against the patient’s wishes, values, or goals.  Medically assisted dying refers to cases in which patients with decisional capacity request that their physicians prepare them and provide the means for them to follow through on their decision to control/manage the time and manner of their death. 


Futile Treatment

Treatment provided to a patient with a life-threatening illness that will do no more than prolong the dying process. Physiologic futility is the utter impossibility that the patient’s condition can be improved by continuing or increasing restorative interventions (i.e., only prolonging the dying process).  Value-based futility (or quality of life futility) is the recognition that continuing or increasing restorative interventions conflicts with the patient’s preferences, values, and goals of care. 


Life-sustaining Treatment 

Treatment that keeps a patient alive but does not itself cure or restore the patient.  Treatments are considered life-sustaining when the patient will die imminently due to the underlying illness or injury if life-sustaining treatments are withheld or withdrawn. 


Withholding and/or Withdrawing Life-sustaining Treatment 

Foregoing life-sustaining treatment includes both withdrawing and withholding of any life-sustaining treatment (including, but not limited to, mechanical ventilation, bi-level positive airway pressure, vasopressors, oxygen, dialysis, antibiotics, blood transfusions, artificial hydration and nutrition).  The same rationale and justification should be applied to withholding and to withdrawing of life-sustaining treatments. Decisions to forego life-sustaining treatments should be based on medical indications in relation to feasible goals of care and should be consistent with the patient’s advance medical directives and/or other documented expressions of the patient’s values and goals (or lacking such guidance, consistent with the best interests of the patient).