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Assault as Treatment: Mythology of CPR in End-of-Life Dementia Care
Many people have come to view cardiopulmonary resuscitation (CPR) as a routine intervention following cardiac arrest, and they insist on CPR for their loved ones even when the physician explains its likely futility. Physicians who refuse a family member’s request to perform unwarranted CPR risk becoming the center of media, legal, and disciplinary scrutiny. Although CPR is largely perceived as a benign life-saving intervention, it inflicts indignity and possibly pain on a dying patient and should not be used when it is unlikely to succeed or to benefit the patient if successful. The growing acceptance of do-not-resuscitate orders for patients with advanced cancer has not spread to families of patients suffering from the late stages of other degenerative or terminal illnesses. Having blunt discussions about the true consequences and risks of CPR might foster greater willingness to abstain from administering CPR to patients unlikely to benefit. (Annals of Long-Term Care: Clinical Care and Aging. 2011;19[5]:31-32.)
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Every now and then, the media seizes on the case of a physician accused of “playing God” for refusing to heed a family member’s request to provide a loved one with cardiopulmonary resuscitation (CPR).1-4 News reports describe the physician’s actions as denying the patient the “benefit of potentially life-saving treatment,” and these reports are replete with inflammatory terms like lack of communication and paternalism. Ethicists from around the country are asked to weigh in on the incident, leading to a string of quotes in which a family’s wishes are pitted against the supposed power of physicians. Some families hire a lawyer, who threatens to sue the physicians and the hospital for breach of duty in providing patient care. A complaint is often forwarded to the discipline committee of the appropriate regulatory body.
The cases highlighted by the media generally share many similarities: the patient is very elderly and has multiple medical problems, including some degree of cognitive or mental impairment that requires major decisions be made by a substitute decision-maker (SDM). In some cases, the SDM is acting congruently with the patient’s previously stated desire for a “full code,” believed to indicate a wish for “full CPR.”
Full code has become a catch phrase in end-of-life care discussions despite the fact that there is no such thing as a full or partial code. CPR has but one meaning—a combination of rescue breathing and chest compressions delivered to someone suffering cardiac arrest. Although recent data suggest that chest compression is the most important component of the resuscitative process, “full CPR” is the only standard followed.
CPR for a patient in cardiac arrest requires approximately 10 minutes of rapid chest compression with or without direct current defibrillation, so why is it that some physicians are so reluctant to undertake this valiant attempt to salvage the life of a patient on the verge of departing it forever? After all, medicine has advanced to such a degree that we routinely extend life in many domains and situations where it was previously inconceivable, and among these life-preserving advances, CPR is often seen as relatively modest. Why have some physicians refused to provide it? And given that many view CPR as such a limited intervention, why are physicians who withhold it from a dying patient later accused of playing God?
The irony in this accusation is that if physicians were to acquiesce to the pleas and threats of family members and perform CPR—essentially allowing pressure from the family to override evidence-based clinical judgment—they would be acting as though they were God. Performing CPR on a patient in the absence of clinical evidence that meaningful recovery is possible misinterprets CPR as an instrument of cardiopulmonary resurrection. If one believes such an act possible, current medical knowledge places it beyond the capability of mortals and into the hands of a deity.5
The real question is what drives educated and otherwise logical people to resist accepting the process of dying in loved ones at the end of terminal stages of diseases whose medical trajectory is fairly well understood. Some progress has been made in getting physicians and the public to let go of patients with terminal malignant disease, but it took decades to achieve this. Although many patients with cancer continue to pursue every fringe treatment they can afford, palliative care for those with very advanced malignancies rarely incorporates CPR in the symptom-management program or as part of the ritual of death. In fact, palliative care and hospice-type settings commonly require a do-not-resuscitate (DNR) order as a condition of admission.
In the field of dementia care, we have yet to reach the point where it is generally accepted by the public and SDMs that a palliative approach to care might be the most clinically appropriate and humane approach for patients at the terminal stage. I have witnessed episodes in which staff members pursuing a DNR order make several attempts to explain the clinical futility of administering CPR for a particular patient and then give up rather than risk complex legal and disciplinary conflicts with family members. Instead, they allow the person they have been entrusted to care for properly and treat with respect to undergo CPR, with its concomitant lack of dignity and likely discomfort. We may never know how much suffering CPR inflicts on patients in the last phase of dying since no one is available to describe the experience. It is also noteworthy that in a study of Medicare data from 1992 to 2005, there was little improvement in outcomes following CPR, with only 18.3% of patients surviving until hospital discharge, and most of these survivors being discharged to hospice, rather than to home, after 1997.6 Older age, male sex, and a higher burden of chronic illness correlated with poorer survival rates following CPR.
For those who are not familiar with the medical literature and the history and progress of CPR, it is easy to forget that the main beneficiaries of this dramatic intervention are those for whom the cardiac arrest is an aberration, such as an otherwise healthy person who is electrocuted or drowns and is rescued in good time or has an untoward event during a surgical procedure. In such individuals, the electrical conduction catastrophe can be rectified by applying CPR, as it is not being caused by a decline in the function of their vital organs; however, the main caveat is that these CPR beneficiaries must have the clinical and protoplasmic reserve to respond to CPR efforts, with the capacity to have good physiological function restored. This is not the picture of a frail elderly individual who has late-stage dementia and multiple medical comorbidities, which is who largely makes up the permanent population at long-term care facilities.
Describing CPR in a more graphic, accurate manner to counter the naïve view of the procedure as a life-saving or life-maintaining intervention that always restores meaningful duration and quality to a patient’s life if successful might help people understand why it should be used judiciously. In cases where the life-saving potential of CPR is less than miniscule and where, even if successful, quality of life will be no better than what it was before the arrest, perhaps we should call the resuscitation process what it truly is: a brutal physical assault on a dying person. This might prevent misguided, undignified, over-zealous misuse of a medical technology created for medical circumstances in which success and meaningful recovery are possible.
In the lexicon of end-of-life or late-stage dementia care, perhaps discussions about options for supportive, caring, and dignified palliative care should represent CPR as a last assault on life. Everyone involved in treating and caring for patients who have often struggled through many years of progressive cognitive decline, invariably coupled with numerous physical indignities and illnesses before death occurs, should shun CPR. One’s last moments should not be sullied by an assaultive, misguided attempt at CPR that ultimately fails and transforms the dying process into something offensive.
Dr. Gordon is professor of medicine, University of Toronto, Baycrest Geriatric Health Care System, Toronto, Ontario, Canada.
References
1. Cribb R. Lawsuit could set precedent about end-of-life decisions. The Star. September 4, 2010. www.thestar.com/news/gta/article/856741--lawsuit-could-set-precedent-about-end-of-life-decisions. Accessed January 13, 2011.
2. Schafer A. Deciding when life ends. The Ottawa Citizen. February 8, 2008. Accessed January 13, 2011.
3. 2 more Winnipeg docs quit over life-support order. Winnipeg Free Press. June 16, 2008. Accessed January 13, 2011.
4. Gordon M. Last rites and rituals. Canadian Jewish News. October 14, 2010. www.cjnews.com/index.php?option=com_content&task=view&id=20008&Itemid=86. Accessed January 13, 2011.
5. Gordon M. In long-term care, the “R” in CPR is not for resurrection. Ann R Coll Physicians Surg Can. 2001;34(7):441-443.
6. Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;36(1):22-31.
