Intended for healthcare professionals

Editorials

Decisions about cardiopulmonary resuscitation

BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6945.1653 (Published 25 June 1994) Cite this as: BMJ 1994;308:1653
  1. D Florin

    Involving patients in decisions about their care is morally, legally, and clinically desirable, whatever their age. The use of do not resuscitate orders, when a decision is made not to give a patient cardiopulmonary resuscitation, is common. In the United States patient consent is a universal requirement for do not resuscitate orders and is enshrined in hospital policies and state law. in Britain this approach is resisted on the grounds that it replaces the humane tradition of medical care with a formulaic adherence to policy.1 But the ethical principle of respect for patients' autonomy and the practical objective of benefiting patients with minimal harm necessitate involving patients in these decisions.2

    We need to establish humane, valid, and reliable ways of ascertaining patients' views. Only when discussing do not resuscitate orders would harm patients, or when cardiopulmonary resuscitation would be futile, should competent patients not be consulted. Three papers in this week's journal concern the withholding of cardiopulmonary resuscitation: Hill et al and Morgan et al have surveyed doctors' and patients' views on cardiopulmonary resuscitation (p 1677,3 p 16774); Doyal and Wilsher discuss the moral and legal implications of do not resuscitate orders for incompetent patients, particularly elderly patients with dementia or stroke (p 1689 5).

    Hill et al and Morgan et al show that agreement is poor between doctors and their patients regarding resuscitation. Hill et al found that most doctors do not believe that patients should be involved in decisions about resuscitation and do not discuss cardiopulmonary resuscitation status with their patients. this survey was of a small sample and had a poor response rate, but the results are borne out elsewhere.6

    In contrast most patients want to discuss cardiopulmonary resuscitation: these studies found that nearly all patients thought that doctors should discuss plans about cardiopulmonary resuscitation with them.3,4 Interestingly, fewer patients actually want to be involved in making the final decision.3,7 This is a subtle distinction that should be explored to establish the most humane way of discussing cardiopulmonary resuscitation with patients. If discussion of do not resuscitate orders is harmful then deciding not to involve patients is justified. but the evidence for harm would have to be better than that currently available: one American series of five patients who became distressed after discussion of decisions not to resuscitate.8

    Do patients want cardiopulmonary resuscitation? Both Hill et al and Morgan et al found that patients are less likely than their doctors to want it. Yet in one group of 67 elderly patients, of whom 60 had been designated not for resuscitation, Liddle et al found that 49 would want it.7 The discrepancy between doctors' and patients' views might partly be accounted for by the tendency of elderly patients to overestimate the success rate of cardiopulmonary resuscitation.9 Murphy et al showed that when elderly American patients were informed of the true success rate the number choosing cardiopulmonary resuscitation halved.10 To make valid choices patients must be properly informed.

    How can doctors ascertain their patients' views? The most obvious way is to ask them. Doyal and Wilsher suggest that explicit discussion of decisions not to resuscitate are unnecessary with every competent patient if patients' views can be inferred from other discussions about the goals of treatment.5 Whether the views inferred in this way are valid and reliable reflections of patients' choices about resuscitation remains to be shown. The views of chronically ill patients may change over time: in one group of patients with motor neurone disease choice changed over six months.11 Patients views need regular review.

    When cardiopulmonary resuscitation is considered to be futile doctors need not discuss or offer it. Broad consensus exists on some of the categories of patients for whom resuscitation has such a poor outcome as be futile. Patients with advanced terminal cancer and those in whom death is expected in a matter of weeks fall into these categories.12 Observational studies have shown poor survival among elderly patients after cardiopulmonary resuscitation (less than 4%) in some settings but much better outcomes in others.13 Old age itself does not mean that cardiopulmonary resuscitation is futile. interestingly, hill et al found that 29% of the senior doctors in their sample would not resuscitate healthy patients over 70, apparently solely on the basis of age. Conversely, one third of doctors stated that they would resuscitate patients with incurable malignancy. At the very least this suggests some disagreement over the conditions for which cardiopulmonary resuscitation is futile. Further work is needed both to establish prognostic indicators for cardiopulmonary resuscitation and to disseminate this information to doctors.

    When patients are incompetent doctors must make choices about resuscitation in their best interests. Doyal and Wilsher state that patients should be considered to be competent unless they are specifically unable to understand the issues and make a rational choice about cardiopulmonary resuscitation. Evidence of incompetence on other issues does not imply incompetence to make choices about resuscitation. Patients with mild or moderate dementia are not automatically incompetent.

    Doyal and Wilsher suggest that cardiopulmonary resuscitation would not be legally or morally in the best interests of patients with severe dementia or stroke who have cognitive impairment equivalent to acute severe brain damage. For incompetent patients with less severe dementia cardiopulmonary resuscitation may still be in their best interests unless their ability to flourish as people is compromised to the extent that they cannot make plans or undertake actions.

    In practice, establishing competence and determining best interests are complex, and not simple algorithm exists. Decisions about resuscitating incompetent patients must be explicit and reached by consensus among the whole medical team. A written policy is one way of making this more likely.14

    References