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• To discuss or not to discuss CPR? That is the question
  Rajeena Ackroyd
  Published on: 23 October 2002
• DNA orders
  Andrew D Lawson
  Published on: 17 October 2002

• Published on: 23 October 2002

  To discuss or not to discuss CPR? That is the question

  • Rajeena Ackroyd, Specialist Registrar in Palliative Medicine

  Dear Editor

  I read with interst the article by Cherniack [1] in October's issue. He questions whether or not more elderly people die with a DNR order beccause they are actually choosing to do so, and reviews evidence of doctors and patients knowledge and attitudes towards CPR decision making.

  It is all very well talking about whether a patient would want to be resuscitated and Cherniack feels more studies...

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  Dear Editor

  I read with interst the article by Cherniack [1] in October's issue. He questions whether or not more elderly people die with a DNR order beccause they are actually choosing to do so, and reviews evidence of doctors and patients knowledge and attitudes towards CPR decision making.

  It is all very well talking about whether a patient would want to be resuscitated and Cherniack feels more studies should be done regarding how elderly people would prefer to be asked, but one has to look at whether CPR is actually going to benefit them or not. I agree that doctor and patient education is important, but I wonder whether emphasis should be placed on education to explain when resusciation would not need to be discussed with patients because it would be unlikely to benefit the patient (medically futile) and explain when it would need to be discussed, when it is likely to benefit the patient or when there is uncertainty on the outcome.

  It is not a question of ignoring a patient's wishes, or age disccrimmination or denying patient autonomy, but to aim to promote the principles of beneficence and non-maleficence, and to do what is in the best interests of our patients.In other aspects of medicine we do not discuss treatments that will not be successful and CPR should be treated in the same way.

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  Conflict of Interest:
  None declared.

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• Published on: 17 October 2002

  DNA orders

  • Andrew D Lawson, Consultant in Anaesthesia & Pain Management, Clinical fellow in Medical Ethics

  Dear Editor

  I read Dr Cherniack's article regarding DNR orders with interest.[1] One of the problems with DNR orders is the patients’ assumption that if there is no DNR order they will survive resuscitative efforts. This of course is far from the truth. In my hospital these have been modified to "do not attempt to resuscitate orders". One cannot be truly autonomous without being informed. Long term survival, as measu...

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  Dear Editor

  I read Dr Cherniack's article regarding DNR orders with interest.[1] One of the problems with DNR orders is the patients’ assumption that if there is no DNR order they will survive resuscitative efforts. This of course is far from the truth. In my hospital these have been modified to "do not attempt to resuscitate orders". One cannot be truly autonomous without being informed. Long term survival, as measured only by being alive, following in-house cardiac arrest, is about 15 % over all age groups.[2] In sick elderly patients over 70 years of age who survive a cardiac arrest, the subsequent hospital mortality approaches 100 %. This fact and concerns about harm influence physician’s attitudes, particularly where the general public have wildly unrealistic expectations of the results of resuscitation as mentioned in the paper.[3] Significant neurological disability is common following cardiac arrest: up to 50 % of the survivors of CPR in one study.[4] Medical staff are clearly aware of hazards of resuscitation, doctors have been demonstrated to be highly selective as to when they would wish resuscitation to take place for themselves [5] and in one group of emergency workers few were found who were willing to undergo full resuscitation as "currently practised".[6] Whilst age per se is not necessarily a predictor of poor outcome of intensive care [7] advancing age is associated with an increasing incidence of systemic diseases, which do predict poor outcomes following arrest.[8,9]

  As a society we seem to strive to prevent death pursuing the next line of treatment at any cost and this struggle against disease has been described as "trench warfare against death".[10] Patients and their relatives expect physicians, as fiduciary agents, to do everything in their power to help cure them and save their lives but there comes a point where not doing something is the better thing to do. Physicians tend to endeavour to do all that they can, as Morreim puts it " embracing a technological imperative that favours action over inaction".[11] However, the fact that we would not wish it upon ourselves says a great deal about what we think of resuscitation in the sick elderly patient. Dr Cherniack comments that when information about CPR is presented more negatively then fewer elderly will chose it. He seems to imply that one could be more positive if only one wanted to. I fail to see how one can be positive about brain damage, a stay on ITU and the near certainty of death. In certain circumstances CPR is simply harmful. Outcome statistics and the high incidence of morbidity have led one group to conclude that, "treating our elders this way is maleficient.[12]

  It is a mute whether there is any moral obligation to discuss treatment options that are not really treatment options, particularly where the potential to do harm far outweighs any benefit. Survivors of resuscitation are transferred to intensive care units. Patients who have spent time on Intensive Care Units report nightmares, depression, high levels of distress and up to 40 % have recollection of pain.[13,14] Is this a beneficent act if survival is not a realistic possibility? I think not but of course a vitalist would disagree. By all means we should ensure that we respect patients autonomy by asking their preferences, but we have to be totally frank about outcomes. To not do so would be to infringe patient’s autonomy as much as disregarding their preferences.

  References

  (1) Cherniack EP. Increasing use of DNR orders in the elderly worldwide: whose choice is it? J Med Ethics 2002;28:303-307.

  (2) Juchems R, Wahlig G, Frese W. Influence of age on the survival rate of out-of-hospital and in-hospital resuscitation. Resuscitation 1993; 26(1): 23-9

  (3) Godkin M, Toth E. Cardiopulmonary resuscitation and older adults expectations. Gerontologist 1994;34:797-802

  (4) Jaffe AS, Landau WM.Death after death: the presumption of informed consent for cardiopulmonary resuscitation--ethical paradox and clinical conundrum. Neurology 1993;43(11): 2173-8

  (5) Hillier TA, Patterson JR, Hodges MO, Rosenberg MR. Physicians as patients. Choices regarding their own resuscitation. Arch Intern Med 1995; 155(12): 1289-93

  (6) Hauswald M, Tanberg D. Out-of-hospital resuscitation preferences of emergency health care workers. Am J Emerg Med 1993;11(3):221-4

  (7) Chelluri L, Pinksy M, Donahoe M, Grenvik A. Long-term outcome of critically ill elderly patients requiring intensive care. JAMA 1993;269(24): 3119-3123

  (8) Bialecki L, Woodward RS. Predicting death after CPR: experience at a non-teaching community hospital with a full time critical care staff. Chest 1995;108:1009-17

  (9) Gordon M, Cheung M. Poor outcome of on site CPR at a multi level geriatric facility: three and a half years experience at the Baycrest Centre for Geriatric Care. Journ Am Geriat Soc 1993;41:163-6

  (10) Callahan D.Death and the Research Imperative. New Engl J Med 2000;342:645-656

  (11) Morreim E. Balancing Act: The New Medical Ethics of Medicines New Economics. 1995 Georgetown University Press, p 13.

  (12) Hilberman M, Kutner J, Parsons D, Murphy D. Marginally effective medical care: ethical analysis of issues in CPR. Journal of Medical Ethics 1997;23:361-367

  (13) Leng C, Lawson A. Pain Management in Intensive Care, Recent Advances in Anaesthesia. 1998 London:Churchill Livingstone.

  (14) Jones C, Griffiths RD, Humphris G, Skirrow PM. Memory, delusions, and the development of acute post traumatic stress disorder-related symptoms after intensive care. Crit Care Med 2001;29(3): 573-80

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  Conflict of Interest:
  None declared.

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