Tuesday, April 24, 2012

When CPR Doesn't Serve a Patient's Best Interests


“What tormented Ivan Ilych most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and he only need keep quiet and undergo a treatment and then something very good would result.”
-- From “The Death of Ivan Ilych," by Leo Tolstoy
Tolstoy prescribed torment for Ivan Ilych in a time long before cardiopulmonary resuscitation and do-not-resuscitate orders. And yet, in “the deception, the lie, which for some reason they all accepted,” Tolstoy could have been writing about a contemporary debate in medicine.
“Something very good” seldom results from CPR on a dying patient. What results more typically is a desperate and pointless act of violence, the very opposite of the “good death” we so commonly wish for. 
The Community Ethics Committee studied the issue in its “Report on Withholding Non-Therapeutic CPR”and the same questions are at the heart of a “viewpoint” in the March Journal of the American Medical Association, “Time to Revise the Approach to Determining Cardiopulmonary Resuscitation Status.” 
There is no question mark at the end of the headline. No, this is a statement of opinion -- that CPR should no longer the default option for dying patients -- from the authors, physicians Craig Blinderman of Columbia University Medical Center and Eric Krakauer of Massachusetts General Hospital, and social scientist/bioethicist Mildred Solomon, president-elect of the Hastings Center.

“Whenever there is a reasonable chance that the benefits of CPR might outweigh its harms, CPR should be the default option,” the authors write. “However, in imminently dying patients, a default status of full resuscitation is not justifiable. Not only is CPR in this situation likely to harm patients without compensatory benefit, the default framework likely influences patients and surrogates to request that full resuscitation is attempted even when the physician believes doing so may be inappropriate.”
When the patient’s surrogates disagree with the medical opinion, the decision whether to withhold CPR pits the value of autonomy against nonmaleficence, or “do no harm.” Is such a case, the authors argue, the patient’s best interests are to be protected from interventions that will provide no therapeutic benefit -- and the patient allowed to die. “While promotion of patient autonomy is a fundamental responsibility of physicians, protecting the patient from harm becomes increasingly important as the patient becomes more vulnerable,” they write. “Sometimes, it should be preeminent.”
How did we get to a place where physicians, against their best judgment, are made to inflict harm on a dying person? In a piece reacting to the JAMA story, Neurology Today provided a useful and concise history.
“When (CPR) was developed 50 years ago, its successes in saving the lives of previously healthy patients who suffered cardiac arrest led to it rapidly becoming standard emergency therapy that would always be performed in the event of cardiac arrest,” physician James L. Bernat writes. Within a decade, however, it became clear that CPR was unsuccessful in nearly all patients dying of chronic diseases, and produced a futile, unnecessary, and violent final end to their lives. Accordingly, the DNR order was devised to prevent the requirement to attempt CPR in those futile circumstances for which it had been neither developed nor intended.”
By now, upon admission, most hospitals require physicians to record whether the patient is a candidate for CPR or is DNR. And CPR has become the “default” treatment.
“CPR is an ‘opt-out’ phenomenon unlike nearly all other therapies which are ‘opt-in,’” Bernat writes. “This difference has led to ambivalence and uncertainty about the role of the physician in writing DNR orders.”
It may be useful to compare the practice to another therapy -- surgery.
“Surgeons DO NOT offer to perform surgeries on patients which have a survival rate of less than 2 percent,” says Dr. Monica Williams-Murphy, an Alabama emergency physician and co-author of “It’s OK to Die.” “Yet, we offer Advanced Cardiac Life Support procedures to people who have these same projected outcomes. There is a big disconnect!”
According to the Community Ethics Committee report, the decision to withhold non-therapeutic CPR “must be made in the context of the patient’s overall goals of care, supported by physiological criteria, and only when the patient and their surrogate and/or family are informed of the rationale for that decision as soon as practicable.”
And if the family does not agree?
“The CEC concluded that withholding non-therapeutic CPR is supportable even when a patient and/or family disagrees with the health care team about the patient’s overall goals of care and demands CPR. That being said, the members of the Committee felt strongly that the withholding of non-therapeutic CPR can only be supported when policies and practices are in place to ensure that patients’ and their families’ interests are protected.”
But how to convince a public swayed by heroic CPR success stories from TV drama that, for a dying patient, CPR is more likely to ensure a bad death than a prolonged life?
“There are interesting data showing that the more informed the public is about exactly what CPR entails, the more likely they are to agree to a DNR order,” Bernat writes. “One study showed a dramatic decline in requests for CPR among elderly residents of a retirement community once they had simply viewed a video of an actual CPR.”

3 comments:

  1. Great post, thank you! There are also data from Joan Teno's group on the impact of conversations with the family members of nursing home residents with dementia on their CPR decisions. Similar data in the ICU from Shannon Carson's group suggest that MDs are frequently not clear in setting the expectation. It seems that the disconnect is most frequently in clear communication between the HCPs and patients/surrogates.

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