A University of Alabama Law School Clinical Program funded in part by West Alabama Regional Commission

4. Definitions

Artificial life support: Use of sophisticated machines such as ventilators and a variety of tubes placed in bladders, veins, arteries, through chest walls to keep individuals alive longer than their bodies can sustain them.

Artificial nutrition and hydration NG (naso-gastric) tube: A tube inserted into the nose, through the throat and esophagus (food pipe) and into the stomach to deliver liquid nutrients. Possible complications are sinus infections, ulcers of the esophagus and stomach, and discomfort such as feelings of bloating or needing to vomit, cramps and diarrhea. Regurgitation is common and can lead to aspiration pneumonia.

PEG (percutaneous endo-gastrostomy) or “G” tube (jejunostomy): A tube threaded through the abdominal wall into the abdominal cavity and then into the stomach. PEG tubes can become displaced, causing liquid to empty into the abdominal cavity. The tubes can cause bleeding, inflammation and infection at entry sites.

Unconscious or confused patients sometimes try to pull feeding tubes out, leading to tying the patient’s arms down, or heavy sedation, which erodes a patient’s mental state and inhibits repositioning for greater comfort.

TPN (total parenteral nutrition): Surgical insertion of a special catheter, usually into a vein just under the collarbone. TPN is usually given to patients with serious intestinal disorders, in anticipation of long term use to maintain a reasonably normal life.

Anoxic brain damage: Death of brain cells due to loss of oxygen. Damage begins about three minutes after blood pressure or oxygen levels fall significantly (such as during cardiac arrest). Many medically frail patients suffer some kind of brain damage that leaves them more impaired than before cardiac arrest.

Cardiac arrest: The point at which the heart stops beating or quivers so that it does not pump correctly. Most cardiac arrests are caused by heart disease that cannot be corrected by CPR. 90% of elderly patients who have cardiac arrests die despite CPR.

CPR or Cardio-Pulmonary Resuscitation: Mechanical compression of the chest, and artificial respiration to sustain a pulse and breathing, often called a “code”. Vigorous chest compression – appropriate in cases in which a patient may recover – can and often does result in broken ribs. Only about 3% of elderly patients with dementia who undergo CPR leave the hospital and some of those suffer anoxic brain damage.

Death by dehydration: Before the development of intravenous fluids most patients died in this manner, which is not uncomfortable so long as the mouth is kept moist and clean. Bodily waste products accumulate and blood pressure drops (hypovolemia) until the patient simply slips away.

Decubiti or decubitous ulcers: Painful bedsores that can occur on heels, buttocks and shoulder blades of patients who are bedridden for prolonged periods.

DNR or “Do Not Resuscitate”and DNAR or “Do Not Attempt Resuscitation Order: In a hospital a “no code” is issued by a physician in appropriate circumstances, with the patient’s consent (or on request). It notifies providers that CPR is not to be implemented if a patient’s heart stops or (s)he stops breathing. These are called “DNR Orders”. Most states, including Alabama, require different orders for hospital and community settings. Without a “pre-hospital DNAR” (do not attempt resuscitation) order, emergency personnel responding to a home call in Alabama must administer CPR even to patients with no hope of recovery.

Foley Catheter: A tube placed in the bladder through the urethra (urinary tube). A balloon on the tip of the tube is inflated after it is inserted into the bladder, to keep it in place. Foley catheters may cause discomfort and a constant feeling of need to urinate.

Intubation – ventilator: The insertion of a tube, about the size of a small finger, into the air pipe through the vocal cords to allow a machine or a person to breathe for a patient. A ventilator is a machine that helps the patient breathe and sustain blood oxygen within normal limits. When the patient wakes up (s)he may be unable to speak until the tube is removed.

Because of discomfort and limited motion, the tube itself, and periodic suctioning of fluids, as well as anxiety, feelings of helplessness and frustration, patients frequently require sedation.

Most of the definitions above were taken directly or adapted from materials distributed by DETA, the Dementia Education and Training Association, developed by the Alabama Department of Mental Health. Some were adapted from materials published by Choice in Dying, predecessor organization to Last Acts Partnership. We thank Dr. Richard Powers for reviewing our adaptation of the materials. Any errors that have slipped in after his review are the fault of the editor; not Dr. Powers.

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