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CARDIOPULMONARY resuscitation (CPR) is a violent activity. Many of those subjected to CPR suffer multiple broken bones or severe internal injuries. For otherwise healthy people who experience a heart attack or an accident, the benefits can outweigh the risks. However, for patients who are dying from life-ending and irreversible illnesses, or have chosen not to have their life prolonged, CPR offers no benefit.
Recently, I heard a doctor speak about the death of his grandmother, who lived in an aged care facility. Nursing staff had called for an ambulance after she deteriorated rapidly. When the paramedics arrived, they found that the woman’s heart had stopped. They believed that they had a duty to start CPR because nobody could produce a valid order not to do so.
Her choice that her life not be prolonged was supported by her family and had been documented in the notes by her GP. However, no written instruction regarding resuscitation was immediately available. After a prolonged period of unwanted and pointless resuscitation, the GP was eventually contacted and ordered that CPR be stopped.
Too often (and yet again last week from another colleague) I hear woeful tales of similar assaults, usually, but not always, on elderly people. One frail older woman who rang “000” when her demented husband collapsed and died was told she must commence CPR pending the arrival of the ambulance.
Some years ago, I too was part of a similar event. We had thought that we had prepared our patient and their family well for a peaceful death at home. Unfortunately, our patient collapsed suddenly and died in the toilet. The family, understandably, called for help from emergency services, who chopped through the door and started CPR because we had not provided a written order not to do so.
CPR shatters the peace of an expected death, destroying what might have been a time of intimacy and tranquillity. While patients cannot report their experience, families and health workers are often hugely distressed by their memories of the death, and may feel guilty that they could not protect the dead person from the onslaught.
About 440 people die every day in Australia. Given the frequency of the stories, I would not be at all surprised if pointless resuscitation were a daily occurrence in our country. The performance of CPR often causes grievous bodily harm – defined in Section 1 of the Queensland Criminal Code as “any bodily injury of such a nature that, if left untreated, would endanger or be likely to endanger life, or cause or be likely to cause permanent injury to health” – and would feature in news bulletins every day were it not being undertaken by health workers as our perceived duty, sometimes at the request of family members, and fulfilling a community expectation.
So how is it that a frail elderly person who has expressed their choice to die peacefully can be subjected to a violent assault that transforms their dying into a miserable, medicalised and undignified nightmare for the participants? Why, after a prolonged period when no effort had been made to slow their decline, are patients suddenly attacked by health workers, or even their own family, when, as expected, their heart stops?
I think these occasions are depressingly common because we have yet to fully rediscover that the job description for doctors includes a particular duty of care to people at the end of their life.
This duty of care holds us generally responsible for integrating into our practice the reality that there comes a time for everyone when further treatment cannot cure our ills or will not help us to a better quality of life.
The complexity of modern medicine leaves us with no choice other than to communicate openly with our patients with life-limiting illnesses so that they can understand the choices we are offering and their realistically achievable outcomes. Failure to do so robs people of the opportunity to decide how to best spend the finite resource of their time in pursuit of their hopes and goals.
As a profession, we can help to ensure that the documents available for Advance Care Planning (ACP) fulfil the complementary needs of patients, their families and clinicians, and that the law in this area supports good medical practice. We can also try to ensure that our health systems use documents effectively, including harmonising ACP across Australia.
As individual clinicians we can encourage and support our patients (and the community generally) to treat dying as a subject for open discussion and appropriate preparation.
And when helping a person with a life-limiting illness and their family to prepare for dying, we must nurture an understanding of the limits of life-prolongation. For example, I explain why we do not offer CPR at the end of life by saying:
“When we die from a progressive illness, our heart stops because we are dying, we don’t die because our heart stops”
or
“Having accepted that a person is dying, it would be irrational to do CPR when the heart stops if we (the patient or their family and the doctor) have decided not to do anything to prevent them from reaching that point”
Patients’ plans for their care at the end of their life can remain unrealised unless doctors create documents that provide clear treatment instructions. Ever since my patient’s door was smashed down, I have tried to ensure that all my patients who are dying, and their families and carers, have available (and know how to use) written doctor’s orders regarding CPR.
Queensland’s doctors can complete an Acute Resuscitation Plan (ARP), which instructs other health workers regarding the scope of treatment (including CPR) that a patient should or should not receive in the event of an acute emergency. Centres that have embraced the ARP (e.g., over 90% of patients who die have an ARP) have found it to be a catalyst for discussion and effective as a means of reducing the risk of unwanted intervention.
We doctors have the duty and the authority to prevent the harm of futile CPR on our patients (other people’s grandmas, grandpas, spouses, siblings and children) when we know they are dying. Avoiding inappropriate resuscitation is our responsibility.
Associate Professor Will Cairns is a palliative medicine specialist based in Townsville and author of the eBook Death Rules – how death shapes life on earth, and what it means for us.
To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.
Thanks Ian,
I agree that it would be worse to incorrectly “not treat” a patient, than to incorrectly “treat” a patient. There is no time to consider and reflect, unless an official document is available, and it would be even better if the family was in control not to call 000.
If you read the current press about a case of dying child ( Google ‘Dr Bawa-Garba case’) in the UK, the doctor inadvertently ordered cessation of resuscitation in an acute admission patient, because he was lying in the bed of a terminal patient with a ‘do not resuscitate’ order.
When called to the ward, she knew the child in that bed was terminal, but did not know the beds had been changed in the previous hour, since she was last in the ward. We all look the same with a facemask and ventilator bag obscuring our features.
Written directives sound OK, until someone waves one in your face and says: “This is my neighbour John Smith, here is his ACD” – How does a locum doctor or paramedic, confirm it is the correct John Smith? Especially if he’s lost 30Kg since his last driver’s licence photo. What if it is Bob Smith who has had an asthma attack on his way up his brother’s stairs, and wants to be saved? Let alone whether the person telling you not to bother resuscitating the body in the toilet is Oscar Pistorius, with a laser-printed fake ACD issued by Dr Harold Shipman.
Even a very obvious tattoo (www.nejm.org/doi/full/10.1056/NEJMc1713344) has no more legal status than the ‘cut here’ transverse wrist tattoos many of my patients have.
In all the cases described in this article, the real problem is that “The family, understandably, called for help from emergency services” – this is not understandable, but an inappropriate call. The expected death of a loved one is not an emergency. The relatives need to be told to contact the palliative care team on a 24 hr number, so a death certificate can be issued and a funeral home called. If help is needed, e.g. to break a door down, the doctor can call the fire brigade or police rescue, either of which have the ability to break a solid door, to come non-urgently.
Otherwise, well meaning bystanders, or certainly ambulance officers doing their job in good faith, are obliged to treat everyone as a candidate for advanced resuscitation. That is never an assault.
I find it very strange to focus on the “violence” of the act. I have often overheard emergency doctors trying to obtain a not for CPR order telling families you don’t want us “jumping on someone’s chest”. I find this can sometimes distract patients and families from the real reasons why CPR is not appropriate. I have had elderly patients refuse not for CPR orders because they feel they are stoic and will be able to brave the CPR and put up with a few broken ribs at the end of it (completely ignoring the likely brain damage that they would sustain if they were to survive). The reality is for the above-mentioned type of patients the violence does not affect them because they are dead and obviously will never recover to feel the pain of broken ribs etc. Like a lot of things in palliative care not for CPR orders are really for the loved ones/carers benefit, not the patient.
Could there be a process for providing patients with a DNR armband similar to allergies or lymphedema warnings? This would then allow ambulance or other staff to see that they did not require CPR.
When end of life discussions are being held, shouldn’t the family members be instructed not to call emergency services for persons who do not want to be resuscitated?
In today’s risk averse and litigious society CPR is inevitable unless there are clear instructions to the contrary and these are known by the attending staff or are immediately accessible in written form. ‘ If in doubt ,resuscitate ‘ is still the safest course in these circumstances. However the points that Prof Cairns makes very valid points about the harm and trauma of futile CPR.
Your assumption is that Ambulance Paramedics are empowered to make discretionary, independent decisions about resuscitation. Ambulance Paramedics work under protocols that are authorised by doctors. Stepping outside this will usually result in punitive measures. If you want to change Ambulance discretion (and Paramedics would love to have more of this to act in a more common sense way rather than a prescriptive manner) you need to focus on the clinicians who are dictating Ambulance protocols in relation to end of life and ACD’s.
I do not see the need for you to introduce the concept of ‘ASSAULT” – surely this will encourage lawyers involvement – costs – anguish for the medical providers and family. This does not improve the argument. I agree limiting or avoiding CPR in the elderly or severely ill individuals. Most nursing homes now have END OF LIFE AGREEMENTS with family implemented for their clients already.
Will, I agree this is a vexed problem. The ambulance officers trie to resuscitate my father even after I told them he had severe COPD and prostate cancer. I had a team in the ED at hospital where I worked trying to resuscitate one of my palliative care patients who was covered in melanoma metastases!
I think palliative care and the ambulance service need to have sensible policy though through – I did try once but met a brick wall.
Anaesthetists Dilemma. I fully agree with the sentiments and thoughts concerning futile CPR- but with one specific exception. I am an Anaesthetist. We have many very ill patients who undergo procedures which they have consented for (with the surgeon and often their families collusion). Not infrequently, I may personally think that both the surgery and procedure are unwise … however, once we have rendered them unconscious, we have an obligation to get them though the procedure, including CPR on occasions .
Sorry: their not there
My 88 year old father had expressed to me and his wife that he didn’t want to be resuscitated and had written information to support his position. He had a heart attack while lighting the fire while at home. Almost a perfect way to end. His wife panicked and called the ambulance and me. When they arrived I told them I was a retired medical practitioner and that he had had no pulse for over 20 minutes, was 88 years old and had increasingly severe dementia. I also told them that there was a written request for DNR but this was negated because we couldn’t produce the piece of paper on the spot. They pushed me aside and started CPR despite my repeatedly voicing the opinion that it was wrong for them to do so they continued. It wasn’t pretty but thankfully the resuscitation did not work. Thankfully as 30 minutes without a pulse would have left him in a vegetative state. I tackled one of the Ambulance team and he said it was out of there hands. If they attended then they had to start CPR.
Clearly a lot needs to change and I thank you Will for your article.