CPR – I might want it now but I don’t want it later

CPRPeople’s views of CPR (Cardiopulmonary resuscitation – an emergency procedure for persons in cardiac or respiratory arrest) are shaped to a large extent by television medical series such as Casualty, E.R. and Holby City: a patient arrests, the healthcare team apply CPR, and the patient either survives or dies. But CPR is generally misrepresented in movies and TV as being far more effective than it is. Many of the patients portrayed are relatively young and fit – not the elderly ill who more rarely survive, or maybe do so temporarily and with cracked ribs as a result of CPR. Only about 3% of elderly patients with dementia who undergo CPR for instance, leave the hospital – and some of those suffer anoxic brain damage. Yesterday’s story about new guidelines raises both the fervent hope that greater respect is being given to our living wills, but also the spectre that emergency teams might somehow not make every possible attempt to save life when life can be saved.

Both of these views are dangerously narrow. The legal principle of respecting a clearly established living will that is applicable in the circumstances is not in dispute. It has been in effect long before England & Wales put it onto a statutory basis, or before Scotland recognised it in a more holistic way. The problem is in the detail. The publicity of legislation helps people to be more aware of patients’ rights in the matter. Improved communications may make it possible for such patients’ wishes to be accorded respect in situations where before it had been impractical. A presumption in favour of preserving life remains. But the problem of making informed choices that will make sense in a clinical setting is an ongoing one.

How can we find out about the reality of CPR? And do doctors have the time and skills to let us understand the medical realities if we have been conditioned to a view that is either misleading or downright wrong?

A patient who attempts to make a blanket do-not-attempt-to-resuscitate-me directive in a living will is in danger of contravening his or her short-term goals. A patient who is determined always (whether by a living will or the absence of one) to seek CPR in the event of an arrest is in danger of contravening his or her long-term goals.

A new article in the Annals of Family Medicine looks at how doctors might ethically assist in decision-making by making us more aware. (A worry of course is that similar techniques could be used to persuade in a non-beneficent way rather than assist.) But if patients have a fundamental misunderstanding of a medical procedure (as it seems do many writing in to the newspapers over the new guidelines) then, before a patient can make an informed decision, that patient needs a clear and unbiased picture of the choices either way.

Meanwhile, nurses are reporting under-treating pain for fear of prosecution over assisted suicide. Respondents in the survey of 2311 nurses acknowledged restricting medication left patients in more pain than necessary and prolonged their lives against their wishes. Said one nurse: “I was worried about the authorities scrutinising the medication record with the intention of prosecuting me for over-medication, even though the dosage was ordered by a physician and necessary to relieve the patient’s pain and suffering.”

Many of these concerns are not about whether there should or shouldn’t be a law on assisted suicide: they point to the need for a comprehensive range of lawful end-of-life options.

Some references & resources:
GMC: Withholding & withdrawing – advice for doctors
GMC: End of life treatment and care – consultation document
Scottish Government Directorate
on Anticipatory Care Planning
BMA/RC/RCN: Decisions relating to cardiopulmonary resuscitation
CFP article:
Cardiopulmonary resuscitation of elderly people in long-term care
Annals of Family Medicine
: Techniques to Improve Patients’ Decisions
JME
: Rational Non-Interventional Paternalism (Savulescu)
NEJM article
: Cardiopulmonary Resuscitation on Television
Nursing Times
: Dying patients denied pain relief because of legal fears
BMA
(doctors’ union) on End of Life issues
Should I Complete an Advance Directive? thought-provoking download (Lifecare)
Elder Abuse: Treatment Without Consent (from End of Life Education)
Example of DNACPR (Do Not Attempt CPR) Policy from NHS Wales

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