EXIT  Newsletter

[EXTRACT:]Techniques for reversing cardiac arrest (Cardio-Pulmonary Resuscitation - CPR) developed 35 years ago to prevent sudden unexpected death. More widespread use led to lower success rates and inappropriate use. The inappropriate "crash call" looms large in British hospital folklore. A junior nurse finds an apparently dead patient and puts out a call. The team rushes to the ward, scattering all in their path. After prolonged efforts a pulse is reestablished only to discover that the patient is demented with metastatic carcinoma. No- one's interests have been served. The patient's last hours are an undignified trauma; the relatives are distressed; the doctors irritated and disillusioned and the junior nurses probably disciplined by unimaginative seniors for their actions.
UK surveys suggest that about 25% of CPR attempts may be "inappropriate." British practice was formerly characterized by either an absence of policies or unwritten, covert policies. Even so, there did seem to be a fear that too much CPR was occurring. A Lancet editorial in 1982 was actually entitled "Cardiac resuscitation in hospital: more restraint needed?" A more recent editorial in the British Medical Journal was frankly paternalistic: "In Britain, sound unhurried clinical judgement, sympathy, understanding and mutual trust, rather than abstract principles and printed policy statements have in general stood patients in good stead.... Better than anyone else the consultant and his team know the nature of the patient's disease or diseases and the likelihood of responding to treatment. Quality of life is relative and should be assessed in relation to the age, state of health and personal aptitudes and interests of each individual patient." In reality, judgements were often simply not made or were delegated to junior staff. The decision was sometimes left to some unfortunate nurse to make on the spur of the moment. The British approach was complacent.
This complacency was punctured by the report of the Parliamentary Commissioner or Ombudsman in 1991. He drew attention to the case of a woman of 88 admitted to hospital with pneumonia. The patient was designated not for resuscitation. The patient's son discovered and complained. The Ombudsman commented that he "found surprising the novelty of establishing a written resuscitation policy." After discussion by a parliamentary committee, the government's Chief Medical Officer wrote to all consultants pointing out their responsibilities. Official bodies responded with guidelines and policy recommendations.
Since the alternative to CPR is death, it is easy to assume that CPR can do no harm. The assumption is wrong. Harm may result to the patient, to the family, to health carers and to society. Clear policies are therefore needed in institutions such as hospitals and nursing homes, to determine "do not resuscitate" (DNR) orders. Many have suggested that a value judgement can be avoided by withholding CPR from those in whom it simply will not work - so called physiological futility. I do not believe this is true. Even five minutes more life might be valued in some (perhaps rather fantastic) scenarios. Many will find it repugnant to give CPR to someone in the persistent vegetative state. Yet the decision is not value free. It is possible that such a life may be greatly valued, that such an individual may still be the focus for someone's love and concern and that an individual may have wanted continuing biological life as long as they could continue such a role. To decline CPR is to deny such possibilities. A few hours extra may enable affairs to be ordered, goodbyes to be made.
The BMA/RCN guidelines state: "It is appropriate to consider a DNR decision... where the patient's condition indicates that effective CPR is unlikely to be successful.... When the basis for a DNR order is the absence of any likely benefit, discussion with the patient, or others close to the patients, should aim at securing an understanding and acceptance of the clinical decision that has been reached."
Autonomy is not enhanced where one choice offers no reasonable prospect of a particular outcome. Doctors do need more education in prognosis. It has been shown that cancer or AIDS are perceived to be terminal, while equally terminal conditions such as cirrhosis or cardiac failure are not. CPR is then inappropriately offered to the latter and, quite correctly, not to the former. Both doctors and nurses in the UK and the US have an over-optimistic view of a patient's chances of surviving CPR. Resuscitation training programmes should routinely include data on survival from CPR in differing circumstances.
Such data need to be distinguished from quality-of-life considerations. There is extreme variability in such estimates by health care professionals. The disabled value a quality of life that many healthy people might consider unacceptable: in a study of 21 patients with spinal injuries requiring ventilation, for example, only one wished to be allowed to die.