Life support comprises the treatments and techniques performed in an emergency in order to support life after the failure of one or more vital organs. Healthcare providers and
emergency medical technician
An emergency medical technician (EMT), also known as an ambulance technician, is a health professional that provides emergency medical services. EMTs are most commonly found working in ambulances. In English-speaking countries, paramedics are ...
s are generally certified to perform basic and advanced life support procedures; however, basic life support is sometimes provided at the scene of an emergency by family members or bystanders before emergency services arrive. In the case of cardiac injuries,
cardiopulmonary resuscitation
Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spont ...
is initiated by bystanders or family members 25% of the time. Basic life support techniques, such as performing CPR on a victim of
cardiac arrest
Cardiac arrest is when the heart suddenly and unexpectedly stops beating. It is a medical emergency that, without immediate medical intervention, will result in sudden cardiac death within minutes. Cardiopulmonary resuscitation (CPR) and possib ...
, can double or even triple that patient's chance of survival. Other types of basic life support include relief from
choking
Choking, also known as foreign body airway obstruction (FBAO), is a phenomenon that occurs when breathing is impeded by a blockage inside of the respiratory tract. An obstruction that prevents oxygen from entering the lungs results in oxygen de ...
(which can be done by using the
Heimlich maneuver
Abdominal thrusts, also known as the Heimlich maneuver or Heimlich manoeuvre, is a first aid procedure used to treat upper airway obstructions (or choking) by foreign objects. American doctor Henry Heimlich is often credited for its creation. ...
), staunching of
bleeding
Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...
by direct compression and elevation above the heart (and if necessary, pressure on arterial pressure points and the use of a manufactured or improvised
tourniquet
A tourniquet is a device that is used to apply pressure to a limb or extremity in order to stop the flow of blood. It may be used in emergencies, in surgery, or in post-operative rehabilitation.
A simple tourniquet can be made from a stick and ...
),
first aid
First aid is the first and immediate assistance given to any person with either a minor or serious illness or injury, with care provided to preserve life, prevent the condition from worsening, or to promote recovery. It includes initial in ...
, and the use of an
automated external defibrillator
An automated external defibrillator (AED) is a portable electronic device that automatically diagnoses the life-threatening cardiac arrhythmias of ventricular fibrillation (VF) and pulseless ventricular tachycardia, and is able to treat them thro ...
.
The purpose of basic life support (abbreviated BLS) is to save lives in a variety of different situations that require immediate attention. These situations can include, but are not limited to, cardiac arrest,
stroke
A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...
,
drowning
Drowning is a type of suffocation induced by the submersion of the mouth and nose in a liquid. Most instances of fatal drowning occur alone or in situations where others present are either unaware of the victim's situation or unable to offer a ...
, choking, accidental injuries,
violence
Violence is the use of physical force so as to injure, abuse, damage, or destroy. Other definitions are also used, such as the World Health Organization's definition of violence as "the intentional use of physical force or Power (social and p ...
, severe
allergic reaction
Allergies, also known as allergic diseases, refer a number of conditions caused by the hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include hay fever, food allergies, atopic derma ...
s,
burn
A burn is an injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction, or ultraviolet radiation (like sunburn). Most burns are due to heat from hot liquids (called scalding), solids, or fire. Burns occur mainl ...
s,
hypothermia
Hypothermia is defined as a body core temperature below in humans. Symptoms depend on the temperature. In mild hypothermia, there is shivering and mental confusion. In moderate hypothermia, shivering stops and confusion increases. In severe h ...
, birth complications,
drug addiction
Addiction is a neuropsychological disorder characterized by a persistent and intense urge to engage in certain behaviors, one of which is the usage of a drug, despite substantial harm and other negative consequences. Repetitive drug use of ...
, and
alcohol intoxication
Alcohol intoxication, also known as alcohol poisoning, commonly described as drunkenness or inebriation, is the negative behavior and physical effects caused by a recent consumption of alcohol. In addition to the toxicity of ethanol, the main p ...
. The most common emergency that requires BLS is
cerebral hypoxia
Cerebral hypoxia is a form of hypoxia (reduced supply of oxygen), specifically involving the brain; when the brain is completely deprived of oxygen, it is called ''cerebral anoxia''. There are four categories of cerebral hypoxia; they are, in o ...
, a shortage of oxygen to the brain due to heart or
respiratory failure
Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a rise ...
. A victim of cerebral hypoxia may die within 8–10 minutes without basic life support procedures. BLS is the lowest level of emergency care, followed by advanced life support and
critical care.
Bioethics
As technology continues to advance within the medical field, so do the options available for healthcare. Out of respect for the patient's autonomy, patients and their families are able to make their own decisions about life-sustaining treatment or whether to hasten death. When patients and their families are forced to make decisions concerning life support as a form of end-of-life or emergency treatment, ethical dilemmas often arise. When a patient is terminally ill or seriously injured, medical interventions can save or prolong the life of the patient. Because such treatment is available, families are often faced with the moral question of whether or not to treat the patient. Much of the struggle concerns the ethics of letting someone die when they can be kept alive versus keeping someone alive, possibly without their consent. Between 60 and 70% of seriously ill patients will not be able to decide for themselves whether or not they want to limit treatments, including life support measures. This leaves these difficult decisions up to loved ones and family members.
Patients and family members who wish to limit the treatment provided to the patient may complete a
do not resuscitate
A do-not-resuscitate order (DNR), also known as Do Not Attempt Resuscitation (DNAR), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), no code or allow natural death, is a medical order, written or oral depending on country, indicating tha ...
(DNR) or
do not intubate (DNI) order with their doctor. These orders state that the patient does not wish to receive these forms of life support. Generally, DNRs and DNIs are justified for patients who might not benefit from CPR, who would result in permanent damage from CPR or patients who have a poor quality of life prior to CPR or
intubation
Intubation (sometimes entubation) is a medical procedure involving the insertion of a tube into the body. Patients are generally anesthetized beforehand. Examples include tracheal intubation, and the balloon tamponade with a Sengstaken-Blakemo ...
and do not wish to prolong the dying process.
Another type of life support that presents ethical arguments is the placement of a feeding tube. Decisions about hydration and nutrition are generally the most ethically challenging when it comes to end-of-life care. In 1990, the
US Supreme Court
The Supreme Court of the United States (SCOTUS) is the highest court in the federal judiciary of the United States. It has ultimate appellate jurisdiction over all U.S. federal court cases, and over state court cases that involve a point of ...
ruled that
artificial nutrition and hydration are not different from other life-supporting treatments. Because of this, artificial nutrition and hydration can be refused by a patient or their family. A person cannot live without food and water, and because of this, it has been argued that withholding food and water is similar to the act of killing the patient or even allowing the person to die. This type of voluntary death is referred to as
passive euthanasia
Euthanasia (from el, εὐθανασία 'good death': εὖ, ''eu'' 'well, good' + θάνατος, ''thanatos'' 'death') is the practice of intentionally ending life to eliminate pain and suffering.
Different countries have different eutha ...
.
In addition to patients and their families, doctors also are confronted with ethical questions. In addition to patient life, doctors have to consider medical resource allocations. They have to decide whether one patient is a worthwhile investment of limited resources versus another. Current ethical guidelines are vague since they center on moral issues of ending medical care but disregard discrepancies between those who understand possible treatments and how the patient's wishes are understood and integrated into the final decision. Physicians often ignore treatments they deem ineffective, causing them to make more decisions without consulting the patient or representatives. However, when they decide against medical treatment, they must keep the patient or representatives informed even if they discourage continued life support. Whether the physician decides to continue to terminate life support therapy depends on their own ethical beliefs. These beliefs concern the patient's independence, consent, and the efficacy and value of continued life support. In a prospective study conducted by T J Predergast and J M Luce from 1987 to 1993, when physicians recommended withholding or withdrawing life support, 90% of the patients agreed to the suggestion and only 4% refused. When the patient disagreed with the physician, the doctor complied and continued support with one exception. If the doctor believed the patient was hopelessly ill, they did not fulfill the surrogate's request for resuscitation. In a survey conducted by Jean-Louis Vincent MD, PhD in 1999, it was found that of European intensivists working in the Intensive Care Unit, 93% of physicians occasionally withhold treatment from those they considered hopeless. Withdrawal of treatment was less common. For these patients, 40% of the physicians gave large doses of drugs until the patient died. All of the physicians were members of the European Society of Intensive Care Medicine.
Case studies
Sawatzky vs. Riverview Health Center Inc., November 1998
Mr. Sawatsky had Parkinson's disease and had been a patient at the
Riverview Health Centre
Riverview Health Centre is a community hospital in Winnipeg, Manitoba, Canada
Canada is a country in North America. Its ten provinces and three territories extend from the Atlantic Ocean to the Pacific Ocean and northward into the A ...
,
Manitoba
Manitoba ( ) is a Provinces and territories of Canada, province of Canada at the Centre of Canada, longitudinal centre of the country. It is Canada's Population of Canada by province and territory, fifth-most populous province, with a population o ...
,
Canada
Canada is a country in North America. Its ten provinces and three territories extend from the Atlantic Ocean to the Pacific Ocean and northward into the Arctic Ocean, covering over , making it the world's second-largest country by tot ...
since May 28, 1998. When he was admitted to the hospital, the attending physician decided that if he went into cardiac arrest, he should not be resuscitated. Mrs. Sawatsky opposed the decision and the doctor complied. Later, the doctor decided that the patient needed a cuffed
tracheotomy
Tracheotomy (, ), or tracheostomy, is a surgical airway management procedure which consists of making an incision (cut) on the anterior aspect (front) of the neck and opening a direct airway through an incision in the trachea (windpipe). The ...
tube, which Mrs. Sawatsky opposed. In response, the hospital applied to have a Public Trustee become the patient's legal guardian and the Trustee consented to the operation. In late October, without consulting another physician or the patient's wife, the physician again made a "do not resuscitate" order after the patient developed pneumonia. Mrs. Sawatzky went to court for an
interim order
The term interim order refers to an order issued by a court during the pendency of the litigation. It is generally issued by the Court to ensure Status quo. The rationale for such orders to be issued by the Courts is best explained by the Latin leg ...
to remove the DNR. The "do not resuscitate" order was withdrawn.
In the case law to date in 1988, the courts decided that a decision to withhold or withdraw treatment was only for the physician to make, not the courts. However, the Manitoba court decided that given the scarcity of related cases and how none of them considered the
Canadian Charter of Rights and Freedoms
The ''Canadian Charter of Rights and Freedoms'' (french: Charte canadienne des droits et libertés), often simply referred to as the ''Charter'' in Canada, is a bill of rights entrenched in the Constitution of Canada, forming the first part o ...
, it would try the case. Previous courts had held that physicians should not be bound by law to provide treatment that they didn't believe the patient would want. Otherwise, the physician would be acting against his conscience and his duty as a physician. However, if the patient disagreed, they can sue the physician for negligence. To avoid this, Justice Beard ruled in favor of the patient. Resuscitation is not controversial and only requires CPR, which would be performed by the first qualified person on the scene. Even if resuscitation was an ethical dilemma, it was minor given that the doctor had allowed resuscitation for several months already. In contrast with related cases in which patients were comatose, Mrs. Sawatzky provided evidence that her husband was able to communicate and believed that he could recover, but the doctor disagreed. The uncertainty of recovery pushed the Court to order the physician to allow resuscitation. Where rulings discuss end of life issues, the question is more, "Is continued life a benefit to this person" instead of, "Is it possible to treat this person". These questions are beyond the scope of the medical profession and can be answered philosophically or religiously, which is also what builds our sense of justice. Both philosophy and religion value life as a basic right for humans and not as the ability to contribute to society and purposely encompasses all people. Mr. Sawatzky fell under the umbrella, so the judge ruled in his favor.
Airedale NHS Trust v. Bland (1993)
The ''Airedale NHS Trust v. Bland'' case was an English
House of Lords
The House of Lords, also known as the House of Peers, is the Bicameralism, upper house of the Parliament of the United Kingdom. Membership is by Life peer, appointment, Hereditary peer, heredity or Lords Spiritual, official function. Like the ...
decision for a 17-year-old comatose survivor of the
Hillsborough disaster
The Hillsborough disaster was a fatal human crush during a football match at Hillsborough Stadium in Sheffield, South Yorkshire, England, on 15 April 1989. It occurred during an FA Cup semi-final between Liverpool and Nottingham Forest in the ...
. He had been artificially fed and hydrated via life support for about three years, but he had not shown any improvement while in his persistent vegetative state. His parents challenged the therapeutic life support at the
High Court and wanted permission to end life support for their son. The Court decided that his "existence in a persistent vegetative state is not a benefit to the patient," but the statement did not cover the innate value of human life. The court interpreted the sanctity of life as only applicable when life could continue in the way that the patient would have wanted to live their life. If the quality of life did not fall within what the patient valued as a meaningful life, then sanctity of life did not apply. The accuracy of a proxy's decision about how to treat a patient is influenced by what the patient would have wanted for themselves. However, just because the patient wanted to die did not mean the courts would allow physicians to assist and medically kill a patient. This part of the decision was influenced by the case ''
Rodriguez (1993)'' in which a British Columbian woman with
amyotrophic lateral sclerosis
Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND) or Lou Gehrig's disease, is a neurodegenerative disease that results in the progressive loss of motor neurons that control voluntary muscles. ALS is the most comm ...
could not secure permission for assisted suicide.
Techniques
There are many therapies and techniques that may be used by clinicians to achieve the goal of sustaining life. Some examples include:
*
Feeding tube
Eating (also known as consuming) is the ingestion of food, typically to provide a heterotrophic organism with energy and to allow for growth. Animals and other heterotrophs must eat in order to survive — carnivores eat other animals, her ...
*
Total parenteral nutrition
Parenteral nutrition (PN) is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion. The products are made by pharmaceutical compounding companies. The person receives a nutritional mix ...
*
Mechanical ventilation
Mechanical ventilation, assisted ventilation or intermittent mandatory ventilation (IMV), is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move air ...
*
Heart/Lung bypass
*
Urinary catheterization
In urinary catheterization a latex, polyurethane, or silicone tube known as a urinary catheter is inserted into the bladder through the urethra to allow urine to drain from the bladder for collection. It may also be used to inject liquids used ...
*
Dialysis
*
Cardiopulmonary resuscitation
Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spont ...
*
Defibrillation
Defibrillation is a treatment for life-threatening cardiac arrhythmias, specifically ventricular fibrillation (V-Fib) and non-perfusing ventricular tachycardia (V-Tach). A defibrillator delivers a dose of electric current (often called a ''cou ...
*
Artificial pacemaker
An artificial cardiac pacemaker (or artificial pacemaker, so as not to be confused with the natural cardiac pacemaker) or pacemaker is a medical device that generates electrical impulses delivered by electrodes to the chambers of the heart eith ...
These techniques are applied most commonly in the
Emergency Department
An emergency department (ED), also known as an accident and emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of pati ...
,
Intensive Care Unit
220px, Intensive care unit
An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensiv ...
and
Operating Room
Operation or Operations may refer to:
Arts, entertainment and media
* ''Operation'' (game), a battery-operated board game that challenges dexterity
* Operation (music), a term used in musical set theory
* ''Operations'' (magazine), Multi-Man ...
s. As various life support technologies have improved and evolved they are used increasingly outside of the hospital environment. For example, a patient who requires a ventilator for survival is commonly discharged home with these devices. Another example includes the now-ubiquitous presence of
automated external defibrillator
An automated external defibrillator (AED) is a portable electronic device that automatically diagnoses the life-threatening cardiac arrhythmias of ventricular fibrillation (VF) and pulseless ventricular tachycardia, and is able to treat them thro ...
s in public venues which allow lay people to deliver life support in a prehospital environment.
The ultimate goals of life support depend on the specific patient situation. Typically, life support is used to sustain life while the underlying injury or illness is being treated or evaluated for prognosis. Life support techniques may also be used indefinitely if the underlying medical condition cannot be corrected, but a reasonable quality of life can still be expected.
Gallery
File:Bundesarchiv Bild 183-1985-0515-011, Schwerin, Bezirkskrankenhaus, Dialysezentrum.jpg, Dialysis center for patients with severe chronic kidney disease
File:BellcoFormula.jpg, Hemodialysis machine Bellco Formula
File:Eiserne Lunge 01.jpg, An iron lung
An iron lung is a type of negative pressure ventilator (NPV), a mechanical respirator which encloses most of a person's body, and varies the air pressure in the enclosed space, to stimulate breathing.Shneerson, Dr. John M., Newmarket General ...
File:Respirator icu.JPG, Ventilator "Evita4" on an ICU
See also
*
Life extension
Life extension is the concept of extending the human life expectancy, lifespan, either modestly through improvements in medicine or dramatically by increasing the maximum lifespan beyond its generally-settled oldest people, limit of 125 years.
S ...
References
{{Reflist
Emergency medical procedures
First aid