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Life support

What happens when a patient battles death on life support?

Life support

Begum Kulsoom Nawaz, the wife of Nawaz Sharif, is very sick and is on ‘life support’. First, I must join all Pakistanis that are praying for her recovery. However, many people, even the educated ones are not sure what life support exactly means. Many medical interventions support life. However, there are some interventions that will keep a person alive and if withdrawn will lead to death.

All patients that are very sick will not be placed on life support just to prevent them from dying. Some not so sick patients or otherwise healthy people that develop sudden catastrophic collapse will be placed on life support in the hope that over a relatively short time they will recover and become able to maintain relatively normal function. The latter group includes most patients that are victims of major trauma.

There are many ‘vital’ organs in the human body and failure of any one of them can be fatal over a period of time. However, the most important organ that keeps us alive is the heart. If the heart stops functioning for any reason, within a matter of a few minutes the brain will suffer irreversible damage. And soon all organs of the body will also shut down.

The other vital organ that if it fails completely can cause immediate death is the brain. However, if the brain is damaged but the basic functions like breathing stay intact then such a person can survive and even have a chance of recovery. We see this in many major stroke patients that will recover significant function over time.

The third organ that can fail and produce death over a matter of minutes is the lung. In sudden catastrophic collapse there is usually a cascade with the heart failing first leading to lung failure and eventually to irreversible brain damage. The heart and the lungs work in tandem and the failure of one eventually leads the other to fail also.

Most of us have heard the term CPR. And most of us have some idea that this has something to do with resuscitating or bringing back somebody that seems on the verge of dying. CPR stands for cardio (heart) pulmonary (lungs) resuscitation. It is used to revive patients whose hearts have stopped beating or who have stopped breathing. Different methods are used to resuscitate such patients.

Once the patients have recovered spontaneous heart function but are still not able to breath then they are placed on a respirator or breathing machine. The respirator is connected to a tube that passes through the mouth and the voice box into the lungs. The early period after CPR is the most critical and many different medicines might be used to stabilise heart and lung functions. Such methods all together are referred to as ‘life support’.

As the patient gets better some of the medicines are withdrawn and eventually an attempt is made to see if the patients can breathe on their own. This is a very crucial step in withdrawal of life support. The most important part of this attempt is the ability of the patient to communicate, move around and participate in their own improvement. In patients that are no longer awake and alert even after a few days of life support a decision will be made about withdrawing life support even if it means that the patient will die.

The decision to withdraw life support in a patient that is persistently unconscious is straightforward in most modern medical institutions. Keeping a person without demonstrable brain function on continued life support is considered medical malpractice. However, there are reasons why some patients might be kept in such a state.

In my experience, the commonest reason why patients without any chance of mental recovery are kept on life support is to allow some time for the family to accept the inevitable or else to allow close family members to arrive from abroad or from a distant place. And yes, religious inclination can also be a reason for maintaining life support.

Sadly Pakistani politicians often use ‘sicknesses’ as political tools. However, I am convinced that the Sharif family is not going to use Begum Sahiba’s severe medical problem to delay their corruption trials or to acquire a sympathy vote by prolonging her stay on life support. And I am sure that doctors responsible for her care will not go along with any such attempt.

For patients that show some signs of mental recovery but are not yet able to breathe on their own, many medical and surgical procedures are needed to keep them in reasonable physical state awaiting neurological/mental recovery. And minimise complications.

The most important thing is to remove the breathing tube passing through the mouth as soon as possible. Such a tube if left in place will in a few days cause overwhelming lung infections. The alternative is to introduce a breathing tube directly into the lungs through the neck bypassing the mouth entirely. This is called a tracheostomy and can now be performed at the patient’s bedside.

The other major need is to provide calories. The body during such extreme stress goes into an increased metabolic state and starts burning up extra calories. Once the fat in the body is used up then the body will start burning up muscle and this weakens the patient and makes it even more difficult to breathe on their own.

Such feeding is usually accomplished by inserting a tube directly into the intestine or the stomach (now done without open surgery) to provide nutrition, fluids and medicines that would otherwise be taken by mouth. Catheters are inserted in the bladder to collect urine and ‘adult’ diapers are used for similar purpose.

Once ‘prepared’ for life support in this way, even a patient with minimal brain function can be kept alive for a long time. Ariel Sharon, prime minister of Israel, survived almost eight years in a coma.

Perhaps the best result after CPR and being placed on life support is in patients that have primarily a heart problem like an irregular heartbeat that once corrected leaves them with adequate heart function. However, it is important to remember that once there is a cardiac arrest, unless reversed within a matter of five minutes, irreversible damage can occur to the brain.

One of the reasons why heart problems have better long term results is because of all the options for support that are available. These extend from heart assist devices all the way to heart transplantation.

Most physicians, nurses and emergency medical technicians are trained to perform CPR. Even in the absence of spontaneous heart activity and breathing, an adequate circulation can be maintained for quite some time allowing transport and definitive support.

In my personal experience I have seen patients being transported from a cardiac catheterisation laboratory after heart catheterisation while undergoing CPR all the way to the operating theatre where they underwent successful heart surgery and went home a few weeks later in pretty good shape.

So I would like to emphasise the need for training physicians and nurses to provide effective CPR. And yes I am talking about hospitals in Pakistan.

Syed Mansoor Hussain

syed mansoor hussain
The author has served as Professor and Chairman, Department of Cardiac Surgery, King Edward Medical University.

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