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• We should not engage in futile discussion of resuscitation
  Idris Baker
  Published on: 9 October 2006

• Published on: 9 October 2006

  We should not engage in futile discussion of resuscitation

  • Idris Baker, Consultant in Palliative Medicine
  • Other Contributors:
    • Luke Feathers, Specialist Registrar in Palliative Medicine, Leicester

  Dear Editor,

  We agree with Schildman and colleagues1 that there is a need for better information about doctors’ and patients' thoughts on resuscitation decision making and that good teaching of medical ethics to undergraduates is likely to be a key step in ensuring sound decision-making by doctors.

  Among their important findings are those showing that most doctors who have been formally trained in clinica...

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  Dear Editor,

  We agree with Schildman and colleagues1 that there is a need for better information about doctors’ and patients' thoughts on resuscitation decision making and that good teaching of medical ethics to undergraduates is likely to be a key step in ensuring sound decision-making by doctors.

  Among their important findings are those showing that most doctors who have been formally trained in clinical ethics at one medical school believe that any competent patient should be engaged in discussion before a “do not attempt resuscitation” (DNAR) decision is made, implicitly including those for there is no prospect of benefit. Interestingly, a significant minority of their sample do not believe this. The authors’ discussion considers only one of the reasons offered by Manisty & Waxman2 for not discussing DNAR, that it may destroy hope. We think that it is not always right to discuss resuscitation decisions with patients explicitly but argue that there are other, better reasons.

  Why discuss treatment options with patients? We should do so because that discussion will inform treatment decisions, which is good for the patient, fair, and respects their autonomy. It ticks all the right ethical boxes. But when a treatment will not be offered because it is somehow inappropriate, we do not normally discuss it unless a patient specifically asks about it. We do not list treatments not on offer; we discuss those which a patient might be in a position to accept or to refuse. Discussion of non-available treatment options ticks no boxes at all because it cannot inform a decision.

  There are two reasonable objections to this claim. One is that an attempt at resuscitation is never inappropriate for a patient who would want it. This claim is implicit in much of the guidance on DNAR decisions but is hard to defend. Why should resuscitation be unique in being offered regardless of the lack of prospect of benefit? There are differences of degree between it and other treatments – in urgency and in necessity – but no other difference in fact. There is no good moral reason to think that we need consent to withhold resuscitation. No good argument is offered for the unique status sometimes accorded to it. Indeed perhaps there is a prima facie case that one should have appropriate consent before attempting, rather than withholding, resuscitation. It may be objected that contemporaneous consent is unobtainable, and this is true; but the consent proposed to withhold resuscitation is necessarily obtained in advance and we regard spontaneous competent advance refusal of resuscitation as valid, so there is no reason to think that advance consent cannot be sought. “When your heart stops because you are dying, a point at which you have arrived in spite of our best efforts,” the consent form might read, “it is proposed that we begin mechanical and pharmacological methods that have ……..% [for advanced cancer patients insert ~0% here] of success, or that may work but cannot serve you any useful purpose.” We all have patients whose chief complaint is that they remain alive, and those who have been subjected to a non- consensual resuscitation complain bitterly. Presumably those who die during an unwanted and non-consensual resuscitation attempt would complain more bitterly still. This prima facie case may of course fall to all sorts of objections, but it highlights the difficulty in the unique claim for resuscitation that consent should be required for withholding and not for treatment. There are, in summary, patients for whom resuscitation stands no chance of meaningful benefit, notably those who are inexorably dying of a known progressive disease3.

  Further, we know that there are harms in attempting resuscitation. The harms are negligible when balanced with the enormous benefit of a life saved, but they are significant when there is no benefit to outweigh them. A person who has already died may not be harmed by the trauma to her body, but one who is about to die and who is subjected to this attempt will certainly be harmed at a crucial moment, the ending of her life. Others are harmed too by resuscitation attempts, including relatives, staff and other patients. Finally the care of patients in general at the end of life would be harmed if dying patients were subjected to this attempt regardless of whether it could work. Considerable advances in end of life care centre around recognising the process and the moment of dying and responding to it appropriately, and are severely compromised when at the very last moment we dive in with measures that can no longer succeed in maintaining life. To put this another way, there is no consistency in caring for a patient as someone who is dying if he is someone in whom resuscitation would be appropriately attempted. If the attempt would be appropriate then the focus of care should be different.

  So for some patients resuscitation is inappropriate in that there is no prospect of benefit and significant potential harms to the patient and others. The other plausible objection to withholding discussion of it arises from the claim that discussing a treatment that will not be offered does some other kind of good by including a person in decisions about their care. It is true that patient involvement in decision-making may be beneficial, which is why it is best practice in dealing with patients at the end of life. In our experience the claim that doing so destroys hope is not universally true; in fact it can foster hope and it is in any case right for other reasons concerned with personal autonomy. But the benefit in discussing a non-available treatment is small for most patients and must be balanced against the harm from the discussion. Most patients are distressed by explicit discussion of end of life matters. This distress can be justified when it achieves something but is unjustifiable when it achieves nothing.

  Therefore, we argue, there is a group of patients in whom resuscitation should not be attempted and with whom it should not be discussed. There are better ways to achieve the goods that we seek for them.

  References:

  1 Schildann J, Doyal L, Cushing A & Vollmann J. “Decisions at the end of life: an empirical study on the involvement, legal understanding and ethical views of preregistration house officers.” Journal of Medical Ethics 2006; 32: 567-570.

  2 Manisty C & Waxman J (2003) “Doctors should not discuss resuscitation with terminally ill patients:FOR” British Medical Journal 2003;327:614-615 (13 September),

  3 Ewer MS, Kish SK, Martin CG, Price KJ & Feeley TW (2001) “Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation” Cancer 2001; 92: 1905-12.

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  Conflict of Interest:
  None declared.

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