Heroic measure

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In the context of medicine, heroic measures refer to any courses of treatment or therapy aimed at saving or prolonging a person's life, despite the potential harm those treatments may cause. Heroic measures are almost always used in the scenario of life-threatening situations, when all other viable treatment options have failed, or there is no better treatment option available. The term is not explicitly defined, but rather associated with other umbrella terms, such as advanced care planning and end-of-life care. In conversations, people may use other terms depending on the context, such as "a Hail Mary situation" to emphasize the desperate needs for such treatment. Enacting sewage detection of the virus during the COVID-19 pandemic is a popular example of a heroic measure activated in a desperate time. [1]

Contents

Examples

CPR

Cardiopulmonary resuscitation (CPR) serves as a popular example of a heroic measure. CPR is a potentially life-saving emergency procedure involving chest compressions and rescue breathing, used when a person's heart stops beating or they are not breathing. [2] While CPR can be considered a standard of care in the healthcare setting, it is often seen as a last-ditch attempt to save a person's life in an emergency. If a person suffers cardiac arrest and is not near adequate medical attention, CPR can be seen as the only viable option to revive the person. Potential consequences of CPR include sternum fracture, rib fracture, lung contusion, artery rupture and hemorrhage, but nevertheless, CPR may be medically necessary when the alternative option is death.

Amputations

Amputations of limbs may be considered heroic measures, but necessary in situations which call for drastic measures. In the event that a limb gets physically crushed or is damaged beyond repair, the only way to save the patient may be to remove the affected limb. For example, persons with diabetes are at risk of nerve damage if they consistently have high blood sugar. [3] This leaves the affected area at risk for infection, and if severe infection occurs and the infected limb is not removed, it can infect the rest of the body, which will most often lead to death. This is also the case with people who leave dangerous infections untreated: the tissue of that limb will begin to die, leaving amputation as the only way to save the person from sepsis as the infection spreads to the rest of the body. [4] However, one can argue the use of a prosthesis after amputation would disqualify this method as an heroic measure, but there are also limitations and negative consequences to prosthesis use. [5] This is more prevalent in isolated areas, where medical attention is very far away.

Cancer and end-of-life planning

Oftentimes, treatments like chemotherapy and radiation are also considered examples of heroic measures. Chemotherapy is a treatment that uses drugs to target and destroy rapidly-growing cells, like cancer cells. [6] Radiation therapy uses high-energy x-rays to kill cancer cells. [7] In medicine, chemotherapy and radiation are commonly used to treat cancer. Though it can be a very effective treatment for cancer, it does not come without its side effects—some of which are more serious than others. For example, some common side effects of chemotherapy and radiation include: fatigue, hair loss, nausea and vomiting, diarrhea, skin changes, and more. [8] These side effects occur because chemotherapy and radiation kill not only cancer cells, but also normal, healthy cells in the body as well. [9] Some more serious side effects that can also occur as a result of these treatments is damage to other organs in the body like the lungs, kidneys, nerves, heart, or reproductive organs. [10] It is even possible for a second cancer to develop many years after chemotherapy. [10] Although chemotherapy and radiation are commonly used as cancer treatments, there is potential harm to the body that can occur as a result of these treatments. However, sometimes there are no other treatment options available to treat the cancer and it is necessary to use chemotherapy or radiation in attempts to treat a person with cancer and save their life despite the side effects that can occur. [11]

Often when people with cancer find that experimental chemotherapies are unsuccessful, end-of-life planning begins to start since that is usually the last line of resort for the person. [12] Although there are arguments on whether end of life planning should be considered heroic since it does not prolong or save a person's life, similar to throwing the surrender flag up in the air. However, the topic is still relevant as unsuccessful heroic measures will usually lead to certain death as they are last resort. There has been concern for Oncology providers preferring to introduce end-of-life planning later after attempting all heroic measures when others argue that it should be emphasized before experimental chemotherapy starts [13] Many palliative care advocates argue that more emphasis should be placed offering this care as a viable option for people when deciding whether to try riskier experimental treatments or opt for a safer route of care.

Ethical considerations

Oftentimes, the use of heroic measures is considered when a person is nearing the end of their life. Many healthcare providers try to work with individuals nearing the end of life to discuss ‘end of life planning”, also known as advanced care planning, to get a better understanding of the treatment that person would like to receive. There are many factors that individuals, families, and healthcare teams must consider when choosing a treatment plan for end-of-life care. The topic of a person's end of life can be a very difficult subject for these individuals, family members, and healthcare providers to discuss, so there can often be misunderstanding between these parties on what type of treatment is best for the person nearing end-of-life. [14] Advanced care planning may be difficult for individuals to consider, but it can be a useful tool for families and healthcare providers when determining treatment and the use of heroic measures in the case when the individual is no longer able to make a decision themselves. [15] Generally, taking a heroic measure in attempts to save someone's life towards the end is more costly than pursuing non-heroic measures for treatment. [16] Overall, this raises questions and concerns regarding the cost of a person's life and if this is a factor that should be taken into consideration during end-of-life planning. Additionally, heroic measures taken during end-of-life tend to be more aggressive and raises concerns about quality of life after and if that is worth being compromised to save a life. [16] Given that the use of heroic measures can also be challenging for healthcare providers to discuss, many institutions now have training and certificate programs specially designed to help healthcare providers overcome barriers associated with end-of-life decision-making. [17] [18]

The considerations regarding the use of heroic measures can be even more difficult to decide on when the individual receiving care is a child. Since this can be a very challenging time for all parties involved, healthcare providers and parents need to have a mutual understanding of what care will be provided for the child. In cases where a minor is old enough and competent, they should be involved in the decision-making process to the best of their ability with parents and healthcare providers respecting the decisions of the child. [19] When making the decision over the use of heroic measures, caregivers and providers should consider treatments in which the benefits to the child outweigh the potential burdens treatment will cause. If there is discourse on whether a potential treatment may be the best choice for the child, providers, and caregivers should consider whether the treatment they will be performing is being done “for the child” or “to the child”. [20] Nevertheless, when facing the potential end-of-life of a child, it is important for healthcare teams to still leave room for hope for recovery as this can improve quality-of-life for children and their families at end-of-life. [21]

See also

Related Research Articles

<span class="mw-page-title-main">Chemotherapy</span> Treatment of cancer using drugs that inhibit cell division or kill cells

Chemotherapy is a type of cancer treatment that uses one or more anti-cancer drugs as part of a standardized chemotherapy regimen. Chemotherapy may be given with a curative intent or it may aim to prolong life or to reduce symptoms. Chemotherapy is one of the major categories of the medical discipline specifically devoted to pharmacotherapy for cancer, which is called medical oncology.

<span class="mw-page-title-main">Leukemia</span> Blood cancers forming in the bone marrow

Leukemia is a group of blood cancers that usually begin in the bone marrow and result in high numbers of abnormal blood cells. These blood cells are not fully developed and are called blasts or leukemia cells. Symptoms may include bleeding and bruising, bone pain, fatigue, fever, and an increased risk of infections. These symptoms occur due to a lack of normal blood cells. Diagnosis is typically made by blood tests or bone marrow biopsy.

<span class="mw-page-title-main">Mastectomy</span> Surgical removal of one or both breasts

Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure. Alternatively, some women can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.

<span class="mw-page-title-main">Do not resuscitate</span> Legal order saying not to perform CPR if heart stops

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 the jurisdiction, indicating that a person should not receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating. Sometimes these decisions and the relevant documents also encompass decisions around other critical or life-prolonging medical interventions. The legal status and processes surrounding DNR orders vary in different polities. Most commonly, the order is placed by a physician based on a combination of medical judgement and patient involvement.

Palliative care is an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses. Within the published literature, many definitions of palliative care exist. The World Health Organization (WHO) describes palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain, illnesses including other problems whether physical, psychosocial, and spiritual". In the past, palliative care was a disease specific approach, but today the WHO takes a broader patient-centered approach that suggests that the principles of palliative care should be applied as early as possible to any chronic and ultimately fatal illness. This shift was important because if a disease-oriented approach is followed, the needs and preferences of the patient are not fully met and aspects of care, such as pain, quality of life, and social support, as well as spiritual and emotional needs, fail to be addressed. Rather, a patient-centered model prioritizes relief of suffering and tailors care to increase the quality of life for terminally ill patients.

<span class="mw-page-title-main">Bone tumor</span> Medical condition

A bone tumor is an abnormal growth of tissue in bone, traditionally classified as noncancerous (benign) or cancerous (malignant). Cancerous bone tumors usually originate from a cancer in another part of the body such as from lung, breast, thyroid, kidney and prostate. There may be a lump, pain, or neurological signs from pressure. A bone tumor might present with a pathologic fracture. Other symptoms may include fatigue, fever, weight loss, anemia and nausea. Sometimes there are no symptoms and the tumour is found when investigating another problem.

Terminal illness or end-stage disease is a disease that cannot be cured or adequately treated and is expected to result in the death of the patient. This term is more commonly used for progressive diseases such as cancer, dementia or advanced heart disease than for injury. In popular use, it indicates a disease that will progress until death with near absolute certainty, regardless of treatment. A patient who has such an illness may be referred to as a terminal patient, terminally ill or simply as being terminal. There is no standardized life expectancy for a patient to be considered terminal, although it is generally months or less. Life expectancy for terminal patients is a rough estimate given by the physician based on previous data and does not always reflect true longevity. An illness which is lifelong but not fatal is a chronic condition.

<span class="mw-page-title-main">Preventive healthcare</span> Prevention of the occurrence of diseases

Preventive healthcare, or prophylaxis, is the application of healthcare measures to prevent diseases. Disease and disability are affected by environmental factors, genetic predisposition, disease agents, and lifestyle choices, and are dynamic processes that begin before individuals realize they are affected. Disease prevention relies on anticipatory actions that can be categorized as primal, primary, secondary, and tertiary prevention.

<span class="mw-page-title-main">Malignant peripheral nerve sheath tumor</span> Medical condition

A malignant peripheral nerve sheath tumor (MPNST) is a form of cancer of the connective tissue surrounding nerves. Given its origin and behavior it is classified as a sarcoma. About half the cases are diagnosed in people with neurofibromatosis; the lifetime risk for an MPNST in patients with neurofibromatosis type 1 is 8–13%. MPNST with rhabdomyoblastomatous component are called malignant triton tumors.

Adjuvant therapy, also known as adjunct therapy, adjuvant care, or augmentation therapy, is a therapy that is given in addition to the primary or initial therapy to maximize its effectiveness. The surgeries and complex treatment regimens used in cancer therapy have led the term to be used mainly to describe adjuvant cancer treatments. An example of such adjuvant therapy is the additional treatment usually given after surgery where all detectable disease has been removed, but where there remains a statistical risk of relapse due to the presence of undetected disease. If known disease is left behind following surgery, then further treatment is not technically adjuvant.

<span class="mw-page-title-main">Cancer survivor</span> Person with cancer who is still alive

A cancer survivor is a person with cancer of any type who is still living. Whether a person becomes a survivor at the time of diagnosis or after completing treatment, whether people who are actively dying are considered survivors, and whether healthy friends and family members of the cancer patient are also considered survivors, varies from group to group. Some people who have been diagnosed with cancer reject the term survivor or disagree with some definitions of it.

<span class="mw-page-title-main">Oncology</span> Branch of medicine dealing with, or specializing in, cancer

Oncology is a branch of medicine that deals with the study, treatment, diagnosis, and prevention of cancer. A medical professional who practices oncology is an oncologist. The name's etymological origin is the Greek word ὄγκος (ónkos), meaning "tumor", "volume" or "mass". Oncology is concerned with:

<span class="mw-page-title-main">Quality of life (healthcare)</span> Notion in healthcare

In general, quality of life is the perceived quality of an individual's daily life, that is, an assessment of their well-being or lack thereof. This includes all emotional, social and physical aspects of the individual's life. In health care, health-related quality of life (HRQoL) is an assessment of how the individual's well-being may be affected over time by a disease, disability or disorder.

<span class="mw-page-title-main">Cancer treatment</span> Overview of various treatment possibilities for cancer

Cancer treatments are a wide range of treatments available for the many different types of cancer, with each cancer type needing its own specific treatment. Treatments can include surgery, chemotherapy, radiation therapy, hormonal therapy, targeted therapy including small-molecule drugs or monoclonal antibodies, and PARP inhibitors such as olaparib. Other therapies include hyperthermia, immunotherapy, photodynamic therapy, and stem-cell therapy. Most commonly cancer treatment involves a series of separate therapies such as chemotherapy before surgery. Angiogenesis inhibitors are sometimes used to enhance the effects of immunotherapies.

Pain in cancer may arise from a tumor compressing or infiltrating nearby body parts; from treatments and diagnostic procedures; or from skin, nerve and other changes caused by a hormone imbalance or immune response. Most chronic (long-lasting) pain is caused by the illness and most acute (short-term) pain is caused by treatment or diagnostic procedures. However, radiotherapy, surgery and chemotherapy may produce painful conditions that persist long after treatment has ended.

Chemotherapy-induced peripheral neuropathy (CIPN) is a nerve-damaging side effect of antineoplastic agents in the common cancer treatment, chemotherapy. CIPN afflicts between 30% and 40% of patients undergoing chemotherapy. Antineoplastic agents in chemotherapy are designed to eliminate rapidly dividing cancer cells, but they can also damage healthy structures, including the peripheral nervous system. CIPN involves various symptoms such as tingling, pain, and numbness in the hands and feet. These symptoms can impair activities of daily living, such as typing or dressing, reduce balance, and increase risk of falls and hospitalizations. They can also give cause to reduce or discontinue chemotherapy. Researchers have conducted clinical trials and studies to uncover the various symptoms, causes, pathogenesis, diagnoses, risk factors, and treatments of CIPN.

Limb-sparing techniques, also known as limb-saving or limb-salvage techniques, are performed in order to preserve the look and function of limbs. Limb-sparing techniques are used to preserve limbs affected by trauma, arthritis, cancers such as high-grade bone sarcomas, and vascular conditions such as diabetic foot ulcers. As the techniques for chemotherapy, radiation, and diagnostic modalities improve, there has been a trend toward limb-sparing procedures to avoid amputation, which has been associated with a lower 5-year survival rate and cost-effectiveness compared to limb salvage in the long-run. There are many different types of limb-sparing techniques, including arthrodesis, arthroplasty, endoprosthetic reconstruction, various types of implants, rotationplasty, osseointegration limb replacement, fasciotomy, and revascularization.

POLST is an approach to improving end-of-life care in the United States, encouraging providers to speak with the severely ill and create specific medical orders to be honored by health care workers during a medical crisis. POLST began in Oregon in 1991 and currently exists in 46 states, British Columbia, and South Korea. The POLST document is a standardized, portable, brightly colored single page medical order that documents a conversation between a provider and an individual with a serious illness or frailty towards the end of life. A POLST form allows emergency medical services to provide treatment that the individual prefers before possibly transporting to an emergency facility.

<span class="mw-page-title-main">Childhood cancer</span> Medical condition

Childhood cancer is cancer in a child. About 80% of childhood cancer cases in high-income countries, can be successfully treated thanks to modern medical treatments and optimal patient care. However, only about 10% of children diagnosed with cancer reside in high-income countries where the necessary treatments and care is available. Childhood cancer represents only about 1% of all types of cancers diagnosed in children and adults. For this reason, childhood cancer is often ignored in control planning, contributing to the burden of missed opportunities for its diagnoses and management in countries that are low- and mid-income.

<span class="mw-page-title-main">Cancer and nausea</span>

Cancer and nausea are associated in about fifty percent of people affected by cancer. This may be as a result of the cancer itself, or as an effect of the treatment such as chemotherapy, radiation therapy, or other medication such as opiates used for pain relief. About 70 to 80% of people undergoing chemotherapy experience nausea or vomiting. Nausea and vomiting may also occur in people not receiving treatment, often as a result of the disease involving the gastrointestinal tract, electrolyte imbalance, or as a result of anxiety. Nausea and vomiting may be experienced as the most unpleasant side effects of cytotoxic drugs and may result in patients delaying or refusing further radiotherapy or chemotherapy.

References

  1. ↑ Orive G, Lertxundi U, Barceló D (June 2020). "Do we really need to invoke heroic measures for early SARS-CoV-2 outbreak detection?". European Journal of Epidemiology. 35 (6): 613–614. doi:10.1007/s10654-020-00654-z. PMC   7286809 . PMID   32529510.
  2. ↑ "What is CPR". cpr.heart.org. The American Heart Association. Retrieved 2023-08-01.
  3. ↑ Walicka M, Raczyńska M, Marcinkowska K, Lisicka I, Czaicki A, Wierzba W, Franek E (2021). "Amputations of Lower Limb in Subjects with Diabetes Mellitus: Reasons and 30-Day Mortality". Journal of Diabetes Research. 2021: 8866126. doi: 10.1155/2021/8866126 . PMC   8328738 . PMID   34350296.
  4. ↑ Molina CS, Faulk JB (2023). "Lower Extremity Amputation". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   31536201.
  5. ↑ Pran L, Harnanan D, Baijoo S, Short A, Cave C, Maharaj R, et al. (August 2021). "Major Lower Limb Amputations: Recognizing Pitfalls". Cureus. 13 (8): e16972. doi: 10.7759/cureus.16972 . PMC   8423325 . PMID   34540383.
  6. ↑ "Chemotherapy". Mayo Clinic. Retrieved 2023-08-01.
  7. ↑ "Radiation Therapy for Cancer". National Cancer Institute (NCI). U.S. Department of Health and Human Services. 2015-04-29. Retrieved 2023-08-01.
  8. ↑ "Chemotherapy and Radiation Side Effects". Cleveland Clinic. Retrieved 2023-08-01.
  9. ↑ "Chemotherapy Side Effects". The American Cancer Society. Retrieved 2023-08-01.
  10. 1 2 "Chemotherapy's Effects on Organs and Body Systems". Health Encyclopedia. University of Rochester Medical Center. Retrieved 2023-08-04.
  11. ↑ van den Boogaard WM, Komninos DS, Vermeij WP (January 2022). "Chemotherapy Side-Effects: Not All DNA Damage Is Equal". Cancers. 14 (3): 627. doi: 10.3390/cancers14030627 . PMC   8833520 . PMID   35158895.
  12. ↑ Islam Z, Pollock K, Patterson A, Hanjari M, Wallace L, Mururajani I, et al. (June 2023). "Thinking ahead about medical treatments in advanced illness: a qualitative study of barriers and enablers in end-of-life care planning with patients and families from ethnically diverse backgrounds" (PDF). Health and Social Care Delivery Research. 11 (7): 1–135. doi: 10.3310/JVFW4781 . PMID   37464868. S2CID   259973340.
  13. ↑ Harrington SE, Smith TJ (June 2008). "The role of chemotherapy at the end of life: "when is enough, enough?"". JAMA. 299 (22): 2667–2678. doi:10.1001/jama.299.22.2667. PMC   3099412 . PMID   18544726.
  14. ↑ Islam Z, Pollock K, Patterson A, Hanjari M, Wallace L, Mururajani I, et al. (June 2023). "Thinking ahead about medical treatments in advanced illness: a qualitative study of barriers and enablers in end-of-life care planning with patients and families from ethnically diverse backgrounds" (PDF). Health and Social Care Delivery Research. 11 (7): 1–135. doi: 10.3310/JVFW4781 . PMID   37464868. S2CID   259973340.
  15. ↑ "Advance Care Planning and Chronic Disease Management | Alzheimer's Disease and Healthy Aging". U.S. Centers for Disease Control and Prevention (CDC). 2019-02-15. Retrieved 2023-08-01.
  16. 1 2 Starr LT, Ulrich CM, Corey KL, Meghani SH (October 2019). "Associations Among End-of-Life Discussions, Health-Care Utilization, and Costs in Persons With Advanced Cancer: A Systematic Review". The American Journal of Hospice & Palliative Care. 36 (10): 913–926. doi:10.1177/1049909119848148. PMC   6711813 . PMID   31072109.
  17. ↑ "Advance Care Planning Course | Healthy Aging". U.S. Centers for Disease Control and Prevention (CDC). 2019-03-29. Retrieved 2023-07-31.
  18. ↑ Anderson RJ, Bloch S, Armstrong M, Stone PC, Low JT (September 2019). "Communication between healthcare professionals and relatives of patients approaching the end-of-life: A systematic review of qualitative evidence". Palliative Medicine. 33 (8): 926–941. doi:10.1177/0269216319852007. PMC   6691601 . PMID   31184529.
  19. ↑ "WMA - The World Medical Association-WMA Declaration of Lisbon on the Rights of the Patient" . Retrieved 2023-08-01.
  20. ↑ Linebarger JS, Johnson V, Boss RD, Linebarger JS, Collura CA, Humphrey LM, et al. (May 2022). "Guidance for Pediatric End-of-Life Care". Pediatrics. 149 (5). American Academy of Pediatrics. doi:10.1542/peds.2022-057011. PMID   35490287. S2CID   248394537.
  21. ↑ Hirata M, Kobayashi K (2022-12-30). "Experiences with the end-of-life decision-making process in children with cancer, their parents, and healthcare professionals: A systematic review and meta-ethnography". Journal of Pediatric Nursing. 69: e45–e64. doi:10.1016/j.pedn.2022.12.004. PMID   36586777. S2CID   255322649.
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