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Diabetes and End-of-Life Issues

The whole world watched in shock as the last years of American Terri Schiavo played out on television screens to depict how death, or near death, could tear a family apart instead of bringing them closer together.

In February 1990, cardiac arrest had left Schiavo with massive brain damage due to lack of oxygen. For more than two months, Schiavo was in coma, after which doctors declared her as being in a persistent vegetative state. After several futile attempts by doctors to revive her via various therapies, her husband Michael petitioned the court to remove her feeding tube. Schiavo’s parents, Robert and Mary Schindler would not hear of it. Because the young American did not have a living will, a trial ensued.

Later, the court ruled in favor of Michael and hence, the feeding tube was removed, only to be inserted again two days later. This was followed by several appeals and government interventions until the federal court finally upheld the original ruling: remove Terri’s feeding tube. This was done on March 18, 2005. Thirteen days later, Terri Schiavo, 41 years old, expired.

Such is the case of a patient with an irreversible condition, in which the absence of a living will or advance directives dealt her family with a serious blow.

Her story, however, has encouraged more Americans to ask their physicians about the necessity of having living wills and advance directives in order to settle end-of-life issues in advance.

Yet, though end of life issues are now more acceptable and openly discussed in the United States, it is the opposite in the Philippines. “They are more practical in the U.S. If the medical condition is irreversible, the patient immediately gives advance directives. These are contained in a document, signed. Some of my patients who come from the States, they come to me with their advance directives,” Dr. Evelyn Esposo, an internist-cardiologist at St. Luke’s Medical Center revealed.

What is a living will?
Dr. Cecilia Gonzales, endocrinologist at Asian Hospital and Medical Center noted that end-of-life issues are all the more shunned when involving patients dying of diabetes complications.

Diabetes currently ranks as one of the leading causes of death worldwide. In the Philippines, more and more people are diagnosed with the disease.

People with diabetes nearing the end of life fall victim to several complications or comorbidities. These are conditions or diseases which exist alongside a person’s primary disease. Specific examples of comorbidities in diabetes are obesity, hypertension, cardiovascular disease, kidney disease, hyperlipidemia, and non-alcoholic fatty liver disease.

These complications or comorbidities cause problems for the patients like difficulty in food intake and neuropathic pain which can shoot up from the tip of the toes to the knees. This kind of pain may be constant and disturbing and can drive a person toward depression.

Thus, caring for patients at this stage is crucial in ensuring a positive quality of life even during a person’s last years on earth and eventually, a dignified manner of dying.

It all starts with information. The patient should be fully informed about his condition – how serious it is, its complications, that if not treated well, it may lead to early death, especially with cardiovascular disease.

This is followed by decision-making. These decisions answer multiple questions associated with patient care such as: Should cardiopulmonary resuscitation beperformed? Should a feeding tube be inserted? Should a ventilator be used when the patient begins to breathe with difficulty? Should he take antibiotics? What particular medical treatment does he want or not want? Should we exhaust all possible means to prolong the patient’s life, or should we just let go?

Questions such as these, and everything else that has to do with caring for and treating the patient, should be addressed. These decisions should be made well before the patient is incapacitated so that family members as well as healthcare providers will not be left in a quandary as to which action to take. At best, these decisions resolve what may probably take place in the light of near death: opposingplans from family members, as what happened in the Terri Schiavo case. These will prevent family members from settling in court. Living wills likewise prevent expensive yet useless life support or life-prolonging interventions that may lead to complications such as infections, drug reactions, persistent pain, even mental deterioration.

Basically, these decisions revolve around the wishes of the dying patient as far as treatment is concerned in case his disease or condition reaches a terminal stage or he is eventually reduced into a permanent vegetative state.

When decisions are made, these should be documented and signed. This is the patient’s living will, sometimes referred to as an advance directive or healthcare directive.

In the United States, a living will is a legally binding document reviewed time and again, and which can only be rescinded by the patient. This is filed with the hospital, a lawyer, and/or a health proxy. It cannot be implemented unless the patient has reached a state of incapacity. Many hospitals and clinics in the United States have forms for advance directives readily available for patients.

Hush-hush issue
In the Philippines though, end-of-life issues are seen in a different light. “Diabetes is a chronic disease and our patients are expected to live for decades after diagnosis. It is not a death sentence and we do not discuss end-of-life issues with a patient if we expect him to live another 30-50 years,” revealed another
endocrinologist.

“As endocrinologists, we try to prolong development of complications,” added Dr. Cecilia Gonzales. “Filipinos basically cannot accept it. They always say, ‘We’ll find a cure for that,’ or ‘God will take care of you.’ Filipino families are so close knit, that to them, parting or death should never happen,” added Dr. Esposo.

Palliative care
Patients at the end-of-life stage may also seek the services of a palliative care specialist whose role is very important. The palliative care specialist sees to it that the patient remains pain-free, gets the right nutrition, and adequate assistance in the management of his insulin and glucose levels, as well as his symptoms. He may also provide psychological, social, and spiritual support.

Essentially, palliative care specialists are on call, at any time of the day or night. They go on home visits to their patients to see to it that care is provided in a timely manner and in accordance to their needs and wishes. By doing so, they help improve the quality of life for their patients and their families in the face of a grave and irreversible illness.

The result is one that everybody ultimately hopes for: a peaceful, dignified death.

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