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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
I think the opt in system is a wonderful idea (all thoughts from the original article, that above and comments taken).
Firstly, I agree with John that it is a very difficult decision for a loved one to make at times (with regards to NFR). It can be a minefield of emotion and families may feel like they are “killing” their loved ones.
It can also be confronting to patients to be involved in this decision themselves especially if they are unaware of the question about to be sprung.
The FUNDAMENTAL GOOD that comes out of an opt-in system is that it FORCES us to have the discussion with patients on admission. It FORCES us to categorise patients with potential futility (be that age, comorbidities etc…), write up the forms and go and speak to them and their families about the issue and make an intelligent decision about persuing resuscitation.
How many of us would support an opt-out system for ECMO?
Why should it be the same for cardiopulmonary resuscitation?
I agree that this is one of the big ethical dilemmas of our time. The philosophical tenet of autonomy has led us blindly down this path. Just because a person has a right to choose his or her treatment from the options offered does not, in my opinion, demand that we offer futile, undignified interventions.
We have now been led to a situation where every frail elderly patient lacking a properly-drawn Advance Directive is confronted by a demand for answers on what is to be done should they suddenly stop breathing or their circulation cease. Most of the time it won’t, of course, during this particular admission but the system obliges us to document their wishes afresh each time.
This process is not usually difficult for the patient. I find most elderly people quite practical about such existential issues. But it can be distressing for the family. If they haven’t had that particular discussion, they may be vexed forever about the decision they make on their loved one’s behalf. If ‘yes, resuscitate’, they may witness a death filled with indignity. If ‘no, do not resuscitate’ they may feel lifelong guilt for having authorised Granny’s killing.
Dr John also makes a very important point about consent. Most junior medical staff do not bother to explain or seek consent before inserting an IV cannula or prescribing antibiotics to a frail elderly patient. These interventions are significant acts of artifical life support. We should be specifically instructed to commence these extraordinary measures before doing so, rather than find a few hours later that we have lost the chance to allow the patient the peaceful, dignified exit that they so wanted.
Thanks to Anonymous above for pointing out some confusion in the quote from Professor Ben White. He was in fact referring to a “guardian’s consent” in cases involving patients without decision-making capacity. The error was made by MJA InSight. Our apologies to Professor White and to our readers. We have corrected the article.
I am a little confused and concerned about the comment attributed to Ben White.
The article suggests that he states that in QLD , it is required by law to gain consent for treatment from the PATIENT , when he patient has “NO DECICION MAKING CAPACITY”. This statement if law seems plainly incongruent.
Perhaps this was an encouragament to refer this scenario to QCAT board here.
I agree with Dr John, above, about NOK. The patient is often the parent of the NOK, some of whom may feel a deep attatchment, but some WILL be waiting to inherit, or have some other non-empathetic itiniary.
To assert, as Dr Ryan seems to, that resuscitation is a basic right by default, has no ethical basis. Arguments in its favour could be extended to the provision of any futile therapy (homeopathy, colloidal silver, prayer, trepanning…) as a default human right, unless we trust the experts in the field to make a judgment about relative risks and harms. I reserve the right to not offer my ICU patients stem cell therapy when such unproven treatment is requested by well-meaning relatives. I go throught he same ethical framework when deciding whether to offer CPR to any individual patient also…
PS (I do recognise the role that trepanning might play in the management of certain neurosurgical conditions…)
As a resuscitationist, I prefer nothing more to providing high quality resuscitation to appropriate patients, training junior staff along the way, so that they too can provide the service widely, and occasionally having life-saving/profoundly positive influences on people’s lives. However, as a palliator, I recognise that the cost of providing these services to the wrong patients are often deeply harmful to both the patient and their loved ones. This balance requires some expertise/professionalism to assess and negotiate, often at very short notice. Whilst it is ideal that the patient is involved in the decision (thus requiring the non-resuscitators who admit such patients to commence the discussions) – often such involvement is impossible. The concept of surrogate decision makers is flawed unless such deputising is arranged by the patient in the cold light of day sometime before they become unwell. The next of kin, as well as being a layperson without the experience/training to fully understand the complexity of such decisions, is often asked to make a decision during a time that is incredibly stressful and time pressured. I strongly believe that a next of kin is an incredibly important resource to learn about the patient’s ethical framework, and also is an important recipient of information about medical decisions that are subsequently made in the patient’s best interest. They should not be expected to make the decisions, however, unless the patient has explicitly requested them to do so.
Resuscitation is a right; the implied consent of those who do not get the choice is a tenet of out of hospital cardiac arrest and trauma resuscitation.
Likewise, refusal of resuscitation is the right of the patient, supported by medical and nursing staff. It is not an administrative option for admission documents. We already have sweeping assessments of the potential quality of life of reuscitation candidates.
Remembering some of the key players in resusctation – nurses and paramedics.
NFR order are poorly managed as it is with poor consistency enlistment of key decision makers, particularly the biased assessments of the elderly. Until a more mature appreciation of the lives of the elderly, the infirm and the traumatic unviable, then an opt in approach to resuscitation is unfounded.
The time to have the conversation, if it has not been documented before, is when the patient is admitted to hospital. It is too late once an arrest has occurred. Family should always be consulted in this process. It is when there is a mismatch of expectations that problems arise.
I find it very interesting that we never ask for “consent” for the very simple decisions in medicine that can certainly cause great harm and have been proven to kill patients (e.g. which antibiotic we choose to use, whether to use saline or colloid or blood products to resuscitate a patient, whether to place a central line or not), and yet in the most difficult of judgement calls that requires the greatest degree of professional knowledge and skill, and where emotional connection with the patient is widely recognised to result in inferior decision making, we suddenly abrogate our professional responsibility and let the least equipped people on the planet (the next of kin) make the decision for us.
This is all about professionalism, balance and communication, and I feel Dr Ryan’s comments, although well meaning and considered, are harmful. I agree the PATIENT needs to be involved in the decision, but I strongly DISAGREE that the patient’s NOK are an appropriate substitute whent the patient is obviously unable to participate. I have encountered many NOK who still carry guilt and other negative emotions related to feeling that “they made the decision to kill their loved one”. This is completely unacceptable and largely driven by those who make comments similar to Dr Ryan.
The most important decision any doctor can make is whether to offer a certain therapy or not. This cannot be given away, and is entirely separate to whether a patient accepts to receive it or not. There is no need to blur these two distinct processes, and plenty of reasons why doing so will result in terrible medicine.
This whole scenario underscores the need for ALL PERSONS to have an Advanced Care Directive, especially those admitted to Care Facilities, or those with severe/chronic/terminal illnesses where they are competent to make such decisions. Otherwise those responsible for their care in situations of acute collapse MUST be able to make decisions based on futility if we are NOT to be faced with the default position of “rights” to CPR, when the outcome is likely to be a severely impaired QOL, or effectively NO QOL AT ALL!
I have seen far too many futile attempts at CPR in patients for whom death was, in fact, their preferred outcome, but CPR was attempted anyway, because the patient’s preference was not known/available at the time of the event when it occurred in the hospital/care facility. Where is the good EHR which can provide this information at the bedside? Please fix the PCEHR fast to minimise thIs experience NOW!
A few years back as an ICU registrar, I had the privilege of attending a CODE BLUE and was happy to have fully resuscitated the elderly 82 years old lady who was admited three days earlier with chest infection, as a private patient of a consultant. Post ROSC and full consciousness, I notified the consultant and went ahead to call the patient’s children, to inform them of what had transpired. Hours later, a full house of the NOK arrived and they were “not pleased” that I “had performed CPR on mum and now has left her with a broken rib”. It was an uncomfortable feeling but I promptly apologised to them and informed them that their mum didn’t have any DNR / NFR orders on her file, that if she did, we wouldn’t have jumped on her chest when she stopped breathing and didn’t have a pulse. Following this discussion, I documented DNR / NFR orders on the patient’s file. This patient made a remarkable recovery and was discharged home the next week. She remained out of hospital as long as I can remember. It was an uncomfortable feeling to be told you have done the wrong wrong, after you have actually saved a life.