The Accreditation Standards for Residential Aged Care state that 'Each resident (or his or her representative) participates in decisions about the services the resident receives and is enabled to exercise choice and control over his or her lifestyle'. 
Many adults fear the loss of autonomy and decision making as they get older. While this does not happen to everyone as they age, illness or accident can affect the capacity of many people to make their own decisions at the end-of-life. Making an advanced care directive or having an advanced care plan in place can provide peace of mind.
Whether a resident is making their own decision or a substitute decision maker is choosing for them they need trustworthy information to assist them. Health care providers may also have concerns about many of these decisions. Discussing these matters requires:
Choosing to forgo futile treatment is not giving up. It does not mean no care will be provided. It means the focus of care is on comfort and dignity and the support of the resident and his or her loved ones.
There are some situations that may cause concern for residents, families and staff. Often they relate to the increasing use of technology to manage serious illnesses.
There is information on CareSearch regarding Resuscitation. Cardiopulmonary resuscitation (CPR) is indicated when someone collapses unexpectedly. It is most likely to be successful if the arrest was witnessed, responded to promptly and early defibrillation is performed - even then the likelihood of the person recovering to leave hospital is low.
When a person is dying of terminal illness resuscitation is unlikely to be successful, will cause harm to the deceased and may interrupt the normal grieving process for family.
There is a plain language discussion about Decision Making and Who decides when resuscitation is no longer an option? within the Canadian Virtual Hospice website.
Pacemakers and Implantable Cardioverting Defibrillators (ICDs)
Pacemakers provide an electric stimulus to increase a slow heart rate. They contribute to quality of life by controlling symptoms of heart failure. They are not usually life sustaining devices.
The continued functioning of pacemakers is usually consistent with the goals of palliative care and will not prevent or delay an inevitable death.
ICDs detect lethal arrhythmias and deliver corrective defibrillating discharges (shocks) and may also act as pacemakers. The two functions can be programmed (turned off) separately. When death is imminent, fatal arrhythmias are more likely due to metabolic changes and organ failure. Shocks will be administered if the defibrillating function has not been turned off.
The defibrillating shocks are painful. They are distressing for both the dying person and those caring for them.
Ideally discussions about the eventual need to turn off an ICD should occur with the cardiologist before or soon after implantation of the device. If it has not been discussed before, it needs to be included in decision making when palliative care planning and not for resuscitation orders are discussed. If possible the resident’s cardiologist should be included in the discussions.
Turning off an ICD will not result in immediate death of the resident. Turning off the ICD allows natural death to occur without painful and futile shocks.