Fred is 78. A retired dock-worker and Navy veteran. At 2 o clock one morning he calls his daughter Dianne, a preschool teacher. “I… Can’t….. Breathe…” He gasps down the phone. His daughter tries to conceal her own panic while telling her frail and increasingly bedridden father not to panic. She dials 911 and paramedics are soon at her fathers side. They obtain a history of congestive heart failure and administer oxygen as well as nitroglycerin and furosemide. On arrival at hospital Fred is seen immediately by an experienced emergency medicine resident who places him on a non-invasive ventilation via a tight-fitting and claustrophobic mask. The resident reads his medical record. The notes from his cardiologist paint a grim picture. Fred has an ejection fraction of 15%. The cardiologist estimates a prognosis of no more than a few months and has recommended palliative care.
Fred is admitted to the Intensive Care Unit (ICU) but fails to improve. The non-invasive ventilation is longer working. The intensivist meets with the tearful Dianne and her husband Mike. Yes, she knew that her dad was sick, and she had an inkling that his medications weren’t helping any more. She didn’t like to think about it but she knew that he would die soon. No they hadn’t spoken about it but she thinks he’d want to live for as long as possible and would value a longer life over quality of life. But no, she didn’t think he’d like to to be kept alive permanently on machines. The intensivist suggests a 48 hour trial of more aggressive treatments. Intubation, mechanical ventilation, vasopressors and inotropes in an attempt to eke another one or two percent out of his flailing heart. The intensivist recommends that if Fred’s heart stops, then he allowed to die peacefully and Cardio-Pulmonary Resuscitation (CPR) not be performed. Dianne isn’t so sure about this. Mike is adamant however – everything must be done that has a chance of prolonging Fred’s life. A day later and the situation is dire. Fred is dying – the medication and machines aren’t helping. The intensivist meets again with the family. Overwhelmed and frightened, Dianne drifts in and out “I’m so sorry…. I have some dreadful news….. Despite everything that we’re doing…. Kidneys failing, liver failing…. Your father is dying…. We should let nature take it’s course….. Comfort and dignity.” Mike interrupts to ask a question; “But if his heart stops you’ll give him the shocks and stuff, right doc?” “No” The intensivist is tactful but firm. “Fred is dying. I wish there were some other treatment I could offer that would make him live for longer but there isn’t. At this stage, with his heart and his other organs in the state that they’re in, CPR simply won’t work. The right thing to do is to make sure that Fred is comfortable and that he has you and Dianne at his side when he passes away”
Is it appropriate for physicians to unilaterally decide who should or should not have a do not resuscitate (DNR) order? Is the decision whether or not to perform CPR or not a medical decision (like whether or not to remove a patient’s gallbladder) or is a decision for the patient or their family that physicians must abide by? The issue has recently been brought to the forefront of many Canadian physician’s minds by a policy document released in 2015 by The College of Physicians and Surgeons of Ontario (CPSO). The document, entitled “Planning for and Providing Quality End-of-Life Care” has the laudable goal of improving end-of-life care for Ontarians by giving physicians guidance on best practice and it particularly emphasises the importance of communication with patients and their families.
In the section on potentially life saving and life-sustaining treatment, the policy gives guidance on the provision of advanced treatments to patients nearing the end of their lives. It offers common-sense advice like engaging in frank and open communication with a patient and their family as soon as a terminal diagnosis is made and considering a time limited trial of intensive care to establish the presence of any reversibility in the patient’s illness. While discussing conflict resolution in the relatively small proportion of situations when patients or their families disagree with the recommendation of a doctor not to provide CPR the policy states: “While the conflict resolution process is underway, if an event requiring CPR occurs, physicians must provide CPR. In so doing, physicians must act in good faith and use their professional judgment to determine how long to continue providing CPR.” It is 4 words in that statement “Physicians must provide CPR” that has intensivists, palliative care physicians and ethicists in Ontario feeling uneasy.
Before examining the CPSO policy and its potential ramifications elsewhere in more detail, we should first review the history of CPR. Cardio-Pulmonary Resuscitation was first developed in the early 1960s as a means of resuscitating young patients with ventricular tachydysrhythmias. In the words of resuscitation pioneer Peter Safar, it was intended for “hearts to good to die.” These words are as true today as they were 50 years ago. No-one would doubt that, when properly performed as part of a well functioning emergency medical system, CPR can produce impressive results in this subgroup of relatively young patients who have a primary problem with their heart, and whose other organs are functioning normally. Rates of successful resuscitation of 40-60% are the norm with 20-40% of patients surviving to hospital discharge (the usual benchmark for CPR success).
Over the years, however, CPR has crept into the care of almost all patients who are coming to the end of their lives. This is despite very limited evidence of it’s effectiveness. Indeed, an early observational study of CPR, in the Journal of the American Medical Association in 1961 states that CPR should only be performed after a physician has decided that it has a reasonable chance of returning the patient to a functional existence. No-one would doubt that CPR is the appropriate treatment for a 67 year old marketing executive who has a cardiac arrest on the golf course due to a Myocardial infarct. But what about the 92 year old woman who lives in a nursing home because her dementia is so bad that she can’t feed or toilet herself, let alone recognise her family? What about the 53 year old teacher who used to climb mountains but is now bed-bound and emaciated with aggressive, metastatic pancreatic cancer and who has just slipped into a coma with his oncologist telling his family that he likely only has days to live, if not hours? Ask any doctor or nurse working in an ICU and they will recount story after story of being asked to perform CPR on these patients and many others like them. Continue asking and some will tell you about nightmares, flashbacks, feelings of having failed their patient. Some will use the words torture and assault to describe CPR in these situations.
Some ethicists think that decision making around DNR orders is best thought of by dividing patients into 3 categories. In the first group are those in whom CPR is always an option. The patient who has some kind of abnormality with their heart, but no significant disease in other organs, and who has a sudden, reversible collapse, Many, if not most, patients in this group will walk out of the hospital and enjoy a quality of life the same as, or similar to that which they enjoyed before having a cardiac arrest. The second group is the largest. These are patients whose heart has stopped as a consequence of a chronic, progressive and ultimately terminal illness. These are people with metastatic cancer, chronic obstructive pulmonary disease (COPD), congestive heart failure and dementia. These are patients in whom most physicians would recommend against CPR but would likely perform it if a patient or their family insisted. The recommendation against CPR comes from evidence showing dismal outcomes, with only a couple of percent of patients leaving hospital – many of those to long term care facility and around half of the survivors dying within a year.
The final group of patients is relatively small but lie at the crux of the controversies that sometimes arise around unilateral DNR orders by physicians. These are patients who are clearly dying and in whom CPR will likely achieve nothing except changing the manner in which the patient dies. These are patients like Fred with chronic illnesses like those above that are so advanced that they are bed-bound and comatose; but also patients in ICU who are critically Ill with infections or injuries that are unable to be controlled with even the best medical care available. These patients are typically on such high levels of support that deterioration portends imminent death. In these patients a frank and tactful discussion between the physician and the family is required. The physician must point out the gravity of the situation, the imminence of death and the fact that CPR will not change this. In the small number of cases where families disagree with this assessment, a second opinion should be offered, and perhaps an ethics committee convened. But if a patient suffers from a cardiac arrest while this process is underway, no physician should be compelled to provide a treatment that will not help their patient.
The public at large already have very unrealistic views about the abilities and limitations of modern medicine. Most get their knowledge of critical illness from TV dramas where death is uncommon. An article in the New England Journal of Medicine in 1997 compared survival from CPR in popular medical dramas at the time with actual survival data obtained from data registries. Survival on TV shows was 67% compared with 30% for registry data. In addition all bar one of the 40 patients who survived their cardiac arrest on TV had perfect neurological function with no disability, whereas a high proportion of real world cardiac arrest survivors end up with some kind of disability.
Because of the large number of deaths and devastating injuries seen in the ICU, intensivists have a deep understanding of the principles of biomedical ethics and fully understand the current desire to increase patient autonomy. But there are 4 pillars of medical ethics. In addition to autonomy there is beneficence, non-maleficence and distributive justice. Encouraging physicians to perform CPR that isn’t indicated may preserve patient autonomy, but it isn’t beneficial, it will cause harm and it potentially affects other patients by filling ICUs with patients who have no hope of survival. Some might argue that not offering CPR as an option harks back to medical paternalism of days gone by. I disagree, I feel that offering a treatment that won’t work to a frightened and overwhelmed family offers nothing but false hope and thus not suggesting CPR in futile situations is entirely in keeping with the modern patient centred practice of medicine.
The medical profession as a whole has to accept some of the blame for the current state of affairs too. The oncologists, pulmonologists and cardiologists looking after patients with chronic, incurable illnesses are often reluctant to discuss end of life issues with their patients, worried that they will lose hope – despite evidence to the contrary showing that early frank and honest conversations and involvement of palliative care teams leads to less symptoms, greater quality of life and may even prolong life. Too often the first time that a patient or his family is told that their condition is terminal is by an intensivist during a deterioration. They rightly ask “who I this stranger and why is he telling me something different to the physician I have known for years?” Disagreements over end of life care become almost inevitable.
The first line of the Hippocratic Oath, sworn by physicians as they graduate from medical school, is “Primum non nocere.” First do no harm. Cardio-Pulmonary Resuscitation is harmful. Anyone who argues otherwise hasn’t seen it being performed. Ribs are broken, muscles spasm violently as thousands of volts of electricity pass through them, a thick breathing tube is forced into the windpipe without anaesthetic, power drills burr into bones to gain access to the bone marrow for administration of fluids and medications. As a society we have allowed this barbaric treatment to continue for half a century because of its potential to save those hearts too good to die. Like all treatments in medicine, harms are balanced against benefits and if the harms outweigh the benefits, the treatment is not offered. Requiring CPR to be performed, against the better judgement of doctors and nurses who do it every day, makes no sense. Requiring physicians to perform CPR in futile situations will not save a single life. Instead it will discourage physicians from having conversations that are already hard to have and will remove loving family and friends from the bedside of a dying patient, replacing them with a hastily assembled team of strangers who will perform a treatment that has become nothing more than a futile ritual. If those 4 words “Physicians must perform CPR” from the CPSO policy spread into policy documents of medical regulators elsewhere in the world, end of life care for dying patients will suffer and dedicated physicians and nurses with years of experience will leave the ICU in their droves and seek a calling elsewhere, rather than perform a futile intervention on their most vulnerable patients.