There was a large national and international response to my column questioning the inappropriate use of cardiopulmonary resuscitation (CPR) among certain patients. Readers, patients, relatives, emergency medical technicians, doctors and nurses wrote describing their good and (mainly) bad experiences of CPR in the frail elderly.
Based on your feedback, the issue is two-pronged: the indiscriminate use of CPR among older people simply because there is no DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) order in place; and in some ways the more worrying scenario whereby signed DNACPR orders are ignored in hospitals and nursing homes.
This response was one of many illustrating the problem of advance directives not being acknowledged.
It came from the daughter of a 96-year- old recovering in hospital from surgery for a fractured hip: “We had discussed CPR (with our mother) should anything happen and we told those in charge our instructions that she was not to be resuscitated.
We went in to say we had asked for her to be left to die but were ordered out
“However, a week after the surgery my mother collapsed. I went to inform the nurses and they took over.
“Put us out of the ward, pulled the curtains and all services flew into the ward of three people. We went in to say we had asked for her to be left to die but were ordered out. We know it was written in red on her chart. We all sat numbed and waited as there was nothing we could do and we were all there, her four children. About 1½ hours later we were shown our mother all white and dead.”
A story from a UK ambulance technician about a call to a 107-year-old man illustrates how not having a DNACPR can be unhelpful:
“I arrived and was met by the daughter and led through to the lounge, where I was presented with a lifeless gentleman receiving CPR from his great grand-daughter . . . I probed a bit further whilst continuing life support to find that this gentleman was suffering terminal liver cancer, a benign brain tumour, advanced vascular dementia, chronic kidney failure and was tube fed.
“The family refused the suggestion that the gentleman be admitted to the hospice for palliative care some days before, and the family had refused a DNACPR – ‘he’d want to come back and keep fighting his illnesses.”
Small bowel obstruction
Of course, there is also the other side of the coin; this from a woman in her early 70s who is glad that she received CPR: “I was admitted to hospital with small bowel obstruction. Treated conservatively initially, I then had a cardiac arrest and developed renal failure.
I would think using CPR in my situation was appropriate
“Luckily for me, medical staff had just arrived on the ward, and I was resuscitated, and my kidneys started functioning some time later . . . I had emergency abdominal surgery the same evening. Eventually, I recovered with very sore sternum and ribs! As far as I am aware I have no lasting effects from cardiac arrest and resuscitation. I would think using CPR in my situation was appropriate.”
But readers also described nightmare scenarios in intensive care units. US physician Jessica Zitter, in her recent book, Extreme Measures: Finding a Better Path to the End of Life, refers to this as the "end-of-life conveyor belt".
Why has CPR become a reflex response in hospitals rather than allowing nature to take its course
She argues that palliative care methods should be used to slow down and derail the typical destructive ICU approach that often torments people it cannot heal.
Why has CPR become a reflex response in hospitals rather than allowing nature to take its course, even when advance directives are in place?
Fear of regulators seems to be part of the problem. Consultant physician at Worthing Hospital in Sussex, Gordon Cauldwell, in an open letter to the General Medical Council, has called on the UK regulator to stop the inappropriate use of CPR. "We need to reinvigorate trust in professionalism across the health system," Cauldwell told The Irish Times.
He acknowledges, however, that ensuring the DNACPR decision is readily available to hospital teams called to a patient who becomes unresponsive can be a challenge.
Guidance at his hospital trust states:
“Clear and full documentation of decisions about CPR, the reasons for them, and the discussions that informed those decisions is an essential part of high-quality care . . . Recorded decisions about CPR should accompany a patient when they move from one setting to another.”
BMJ columnist Iona Heath makes the point that the default position for most medical interventions is that patients have to opt in by giving informed consent for the procedure.
“Why should this not be the position for CPR?” Dr Heath asks. “Those in previously good health and who therefore have the best chance of survival after CPR would be likely to opt in without hesitation, but those already in poor health would have to be offered a realistic assessment of their prospects if they needed resuscitation.”
An Irish consultant anaesthetist had this to say: “With advancing ability to treat older patients should come the wisdom and skill of knowing what are the limits of such capability . . . As one who assesses patients for admission to the intensive care, it is important to explain to patients and family members the exact detail of what actually happens following a CPR episode in a fragile patient: intubation, dialysis, complex IV access; and poor outcomes in many situations.”
Hiqa mandate
A spokesperson for the Irish College of General Practitioners (ICGP) said it fully supported a mandate from Hiqa that all residents in nursing homes have adequate end-of-life care planning.
The college also supports the Forum on End of Life Ireland initiative called Think Ahead. Think Ahead helps members of the public talk about and record their preferences in the event of emergency, serious illness or death.
“Choosing not to have full CPR – or to have a component of CPR – does not preclude the full and active management of a medical condition or indeed hospitalisation. All persons should think ahead and consider their end of life choices,” it noted in a statement.
Dublin GP Brian Meade, chair of the ICGP nursing and care home group, says it can be a challenge to pinpoint the right time to have these conversations with nursing home residents.
“The situation has to be handled very sensitively with a need for planning for the conversation – it’s not as simple as saying to someone do you want to be resuscitated if you have a heart attack?” And there is frequently a lack of agreement among family members faced with making a DNACPR decision in a relative with cognitive impairment, he says.
But what of the worrisome stories of written DNACPRs being ignored? Simon Mills, barrister and co-author of the forthcoming book Medical Law in Ireland, says "anecdotal evidence tends to suggest that documents prepared by patients with the aim of refusing future treatment are not infrequently ignored by doctors".
And while there are a number of valid reasons why this might happen, Mills says those who survive a life-saving intervention carried out despite the existence of a “clear applicable refusal of treatment” may be able to mount a legal claim of assault/trespass to person.
Damaging use
It’s time for firm action to stop the inappropriate and damaging use of CPR. It will take education of the public about the limits of the treatment; action by the Medical Council and other regulators to ensure professionals do not fear sanction when they facilitate ordinary death; and a much clearer and more robust system in hospitals to ensure out of hours clinical teams are aware which patients have signed up for DNACPR.
In addition, the planned reorganisation of the Irish health service must recognise and recompense the time required to properly discuss end-of-life issues with patients.
Doctors die, too. What’s unusual about us is not how much treatment we get compared to most patients, but how little. We have good insight into what lies ahead should we be diagnosed with a late-stage cancer.
We certainly know the choices, and find it easier than most to access the level of medical care we want.
When my time comes, I am determined to go gently. I feel reasonably confident that my wishes will be met. But it is deeply regrettable that for many lay people in Ireland, such confidence in modern medicine would be sadly misplaced.
The difference between cardiac arrest and ordinary dying
Imagine for a moment the fragile body of a woman in her 90s after it has been subject to vigorous and unsuccessful cardiopulmonary resuscitation (CPR). Rib bones will have been crunched, soft tissue bruised and teeth broken.
It’s not the way most people want to leave this world. So when is CPR the appropriate treatment?
Despite its extensive use on TV medical soaps, the indication is actually quite limited.
If someone has a sudden cardiac arrest and collapses after their heart unexpectedly stops beating, then immediate CPR can be life-saving.
It is an appropriate response on a playing field or when someone has a cardiac arrest on the street. A trained bystander and a defibrillator can significantly improve the chance of surviving such an event.
What then is ordinary dying? It involves a deterioration in a person’s health over months, days, hours, minutes and seconds until finally the heart stops.
Accepted as a normal event before the advent of high-tech medicine, some health professionals and lay people now appear to struggle with the concept of “going gently into the good night.”
Which, given our increasing longevity and the prevalence of chronic diseases such as dementia,whose natural conclusion is ordinary death, is unfortunate.
Readers may find Let Me Decide, a booklet by Drs William Molloy and Brian Daly, a helpful guide to this area. Newgrange Press, 2017, €12
