"Do not resuscitate" a medical viewpoint

"Do not resuscitate"..... a medical viewpoint

Cardiopulmonary resuscitation (CPR) was first used in 1960. It was immediately seen to be beneficial in cases of cardiac arrest where this had occurred suddenly and unpredictably. It was so successful in fact that it began to be used in situations where the outcome was less predictable. The use of CPR has become so widespread that in the USA it has almost become part of the dying process. There is a place for CPR as a treatment option, but like any treatment option there should be guidelines about when it should be attempted.

If you want to assess the appropriateness of a treatment you have to have some idea about the success rate.

1) In the setting of a coronary care unit if a patient has a cardiac arrest , the chances of a successful CPR is very high. CPR is therefore an appropriate and life saving procedure.

2) An elderly patient who is confined to a wheelchair is admitted to hospital because of a pneumonia, if that person has a cardiac arrest, then the chances of a successful outcome of CPR is minimal. In a number of studies in the medical literature the probability of that person being restored to their previous level of health is of the order of 1% or less.

Although there is active debate as to the exact definition of futile treatment, this would suffice as a benchmark for me. In this case CPR is not indicated, certainly not on medical grounds. Whether the recommendation that a no CPR order should be discussed with the patient is a very contentious area. Personally I do not feel compelled to do so because logically it is futile to discuss a treatment that is highly unlikely to benefit that patient A number of times that I have discussed the subject under these circumstances there has been a considerable amount of misunderstanding, patients may feel that I am suggesting withdrawing all treatment.

On other occasions when I have discussed CPR (when I actually think that CPR is highly unlikely to be successful) the patient has opted for CPR. Should I respect that patient’s autonomy and order CPR, should I hand over the care of that patient to a colleague because I should not be involved in a treatment which I believe is against my moral and medical judgement. What happens if that patient becomes severely depressed as a result of what I discussed. There are many who would argue that it is a patient’s right to know, there are still many people who say “ it’s up to you doc “


3) Somewhere in between these two extremes there exist a large number of patients with chronic disease in whom it would be very important to know whether they would want CPR. In fact we fall well short of this ideal. There are many reasons why this knowledge is not gained.

a)There is a degree of reluctance amongst doctors to discuss such matters of life and death. It is sometimes not the easiest thing to do.

b)There is a matter of timing, should you discuss the matter of CPR at the same time as you have just diagnosed their leukaemia. You run a major risk of sending a rather confused message to the patient.

c) In a sense it is easier to delay any discussion until the subject of CPR is more relevant such as when that patient actually becomes ill. The risk you run here is that the patient may for various reasons be less able to make an informed decision, they may be in a coma, they may have many medical and nursing interventions going on so that their ability to process the information is severely impaired even though they are actually competent in terms of making a decision.

d) The concept of an advanced directive is gaining ground, you say what you do and do not want in terms of medical intervention, by discussing CPR ahead of needs in a sense is getting a very limited advance directive. Unfortunately in many situations the instructions are very vague, also the practice of having advanced directives is pretty uncommon in my experience.

e) An important barrier to discussion I am sure is lack of time. When you discuss end of life matters, you cannot do it in a perfunctory way. In a recent study from Dunedin half of the time that DNR orders were in place, the patient did not die.

f) You could give all the information about CPR in an admission information booklet. Patients would then be encouraged to ask about the policy on CPR. This approach will eventually serve to contribute to the education of the public.

On which subject I would like to briefly discuss an interesting paper which appeared in the New England Journal of Medicine. Almost without exception when surveys are done on the perception of the success rates of CPR, the estimates are very optimistic. It is important when one is discussing the issue of CPR that the information known by both the patient and the doctor is accurate. Patients learn from many sources including friends, other medical and nursing professionals and the media. If you just watched E.R.,Rescue 911 or Chicago Hope your chances of getting out of hospital alive and back to normal are 67%. The majority of arrests were in younger people and due to dramatic problems like near drowning or major trauma. This is wildly different from the reality of hospital where the majority of patients having a cardiac arrest are elderly and suffering from multiple pathology.

There is a long way to go in terms of education of all those involved in CPR and no CPR. We have to give the public a more accurate picture of the success of CPR, not as an isolated treatment, rather it needs to be seen in the context of an illness and in terms of the likelihood of success. As medical and nursing professional we need to improve our knowledge about patients wishes ahead of time, this is not an easy task. Finally in an era of informed consent, I think it would be a shame if we were compelled to discuss all aspects of CPR with patients in what are deemed to be medically futile situations. All patients do not necessarily want to be involved in such discussions. Surely an element of trust should remain that enables us to make a decision as to how we approach this delicate matter. We are after all trusted as professionals in making other important decisions that sometimes involve life and death, why should this subject be any different.