Opt-in CPR dispute

A CONTROVERSIAL proposal to end cardiopulmonary resuscitation as the “universal default” for hospital inpatients and replace it with an opt-in system has generated heated debate among doctors and lawyers.

In a “For debate’” article published today by the MJA, Associate Professor Michele Levinson, head of the department of medicine at Monash University, Melbourne, and research fellow Amber Mills, challenged the idea that cardiopulmonary resuscitation (CPR) was a patient’s right, arguing that “a CPR discussion should occur on admission for all elderly hospital inpatients”. (1)

They argued that this approach might overcome some of the shortfalls of relying on not-for-resuscitation (NFR) orders, which were underutilised and involved time-consuming discussions.

“A focus on patient and family involvement may result in an expectation that CPR is an entitlement”, they wrote.

Instead, they argued that CPR should be regarded as “a medical procedure like any other that should be offered only to those patients for whom it is likely to be beneficial”, saying doctors were under no obligation to provide treatment where no benefit would be conferred.

The authors wrote that a judgement of “futility” could be considered for patients with conditions such as advanced dementia, advanced heart failure, end-stage renal failure where dialysis was not an option, advanced frailty, recurrent aspiration, large stroke with poor functional recovery, end-stage chronic obstructive pulmonary disease, and advanced malignancy refractory to treatment.

Even though the relatives of patients may “test the medical practitioner’s determination of futility in the Supreme Court”, the authors wrote that doctors should be encouraged and supported to “make a deliberate decision about resuscitation, rather than rely on the default approach”.

“If the patient or family disagree with the health care team, there needs to be an ethical decision made weighing up the harm to the patient by providing CPR with the harm to the trust between the patient and family and the health care provider by not providing CPR”, they wrote.

However, Dr Christopher Ryan, from the Centre for Values, Ethics and the Law in Medicine at the University of Sydney, challenged the assumptions of the article, arguing that “in some respects, CPR is an entitlement”.

Dr Ryan told MJA InSight it was “overly simplistic” to suggest that doctors alone could decide if a treatment was futile. “There are non-medical factors in the decision about whether to commence CPR, including patient preferences and values”, he said.

“Certainly what a doctor says should have sway, but it’s not determinative. Where there’s dispute between a patient and a doctor, you go to a third party like an ethics board or the courts.”

Dr Ryan agreed that conversations about CPR and NFR orders were time-consuming, but said they were nonetheless important. “These conversations are one of the time-consuming things we doctors just need to do.”

He said it was hard to see how an opt-in system would work. “Would it be a tick-box system, where doctors would not resuscitate a patient if they hadn’t ticked a box? I can’t see that working. Most patients aren’t thinking about death or CPR when they arrive at hospital.”

Professor Ben White, of the Australian Centre for Health Law Research at the Queensland University of Technology, cautioned that in Queensland there was a legal requirement for doctors to seek a guardian's consent for an NFR order in cases involving an adult without decision-making capacity. In all other states, and in emergency situations, no such consent was required, he said.

However, Professor White said informed discussion about CPR should be encouraged, with doctors taking into account each patient’s particular needs.

“Doctors can and should offer their clinical experience as to the likelihood of success of CPR or not”, he told MJA InSight. “But a decision about CPR is one that should occur with patients or substitute decisionmakers, not without them.”

Professor Cameron Stewart, pro dean and professor of health, law and ethics at the Sydney Law School, said the debate article was “deficient both on the policy front and the legal front”.

He said there was ample advice available for doctors on how to build consensus with patients on end-of-life issues, including the Australian Health Ministers’ Advisory Council’s framework for advance care directives, and NSW Health’s policies on end-of-life care and CPR decisions. (2), (3), (4)

He also directed doctors to clinical practice guidelines published in the MJA. (5)

1. MJA 2014; Online 28 July
2. AHMAC 2011; A national framework for advance care directives
3. NSW Health 2005; End-of-life care and decision-making — Guidelines
4. NSW Health 2008; CPR — Decisions relating to no cardiopulmonary resuscitation orders
5. MJA 2007: 186: 77