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Question: My husband has cancer and has ended up in the hospital several times because of complications from his illness. On a few of those hospital stays, doctors have asked if my husband wants CPR [cardiopulmonary resuscitation] should his heart stop beating. I am worried that they are going to give up on him if he agrees to no CPR. Why do they keep asking him the same question about CPR?
Answer: These are not easy discussions and you are understandably feeling protective of your husband. But keep in mind that a patient’s condition – and attitude about treatment – can change over a period of time. That’s why it’s important for medical staff to ask these questions more than once.
“It is not a one-time conversation,” explains Dr. Rob Fowler, an intensive care physician at Sunnybrook Health Sciences Centre. “It’s often very relevant to reassess the goals of care.”
Ideally, Dr. Fowler says, “we want to raise the issue directly with the patient.” If the person isn’t able to communicate, then the doctors will seek out the substitute decision maker, which is often a family member.
There are many common misconceptions about CPR – created, in part, by prime-time medical television programs showing patients being brought back almost miraculously from the brink of death. There’s no doubt that CPR can be a lifesaver in certain situations. But CPR is not quite as successful as it’s portrayed on TV.
Dr. Fowler points to a study published in the New England Journal of Medicine in 1996. The U.S. researchers looked at the use of dramatized CPR in three TV medical series – ER, Chicago Hope and Rescue 911.
“The success rate of CPR in the TV shows was about 70 per cent,” says Dr. Fowler. “The reality, of course, is different and it depends on the context.”
On average, probably less than 20 per cent of patients who receive CPR in hospital survive long enough to be discharged, he says. That rate drops precipitously with the severity of the illness.
“If you do CPR on patients who are very sick, advanced in age, or have terminal illnesses, the success rate dips into the low single digits,” says Dr. Fowler.
More recent studies have found that the newer medical dramas on TV also leave viewers with an incomplete picture of CPR. What’s often left out is the downside of the treatment, which can be very hard on frail patients.
CPR involves a series of very strong chest compressions. “They have to press down hard on the chest bone to force your heart to pump blood,” explains Sally Bean, a Policy Advisor and Ethicist at Sunnybrook. In effect, the doctors are trying to squeeze your heart from the outside of your body.
“It’s a lot of force on the chest and usually you break ribs by doing it,” says Dr. Fowler. Internal organs can be damaged, too.
Depending on the heart rhythm (or electrical signals), the patient may also receive a powerful electric shock to the chest in order to restore a normal heartbeat.
Some patients are intubated – a procedure in which a tube is inserted down the throat to deliver oxygen directly to the lungs.
“None of these things are pleasant,” says Ms. Bean. “But if the person can benefit and survive then the potential harm caused by the interventions can be worth it.”
Many years ago, CPR was performed in a limited number of situations such as near drownings, heart attacks, or other cases in which the heart suddenly stops pumping oxygenated blood throughout the body. If patients survived the experience, many could expect to go on and live normal lives.
But over time, CPR has become the default treatment in almost all cases of cardiac arrest. This includes hospital patients whose vital organs are shutting down as part of the end stage of chronic or terminal diseases. CPR may restart the heart, but the underlying reason it stopped in the first place cannot be fixed or reversed. The patient could well suffer another heart stoppage in the near future. And, in the meantime, the brutal process of resuscitation has actually left the individual in a great deal of pain and in worse condition overall.
There may be damage to other organs, including the brain, from an extended period without oxygen before the heart was restarted.
“Sometimes mental function is less than what it was before the resuscitation,” says Dr. Fowler. “And we certainly don’t like doing therapies that bring people to a worse quality of life.”
Indeed, it’s important for doctors to talk to patients – or their substitute-decision makers – about care goals soon after they are admitted to hospital. Otherwise, CPR usually becomes the default therapy for cardiac arrest.
If a person doesn’t want CPR, this information is recorded in the patient’s medical charts, so his or her wishes are known to the other hospital staff members who are providing care. The no-CPR order remains in effect for only that one hospital admission. The next time the patient is back in hospital, the CPR order would need to be evaluated again. So the decision is by no means permanent.
Aside from forgoing CPR, everything else about a patient’s treatment will remain the same.
“Patients continue to receive other types of care that are appropriate” for managing symptoms and reducing discomfort, says Ms. Bean. That might range from antibiotics up to and including the fairly aggressive therapies provided in the hospital’s intensive care unit.
Nonetheless, there is a common misunderstanding that ‘no CPR’ is another way of saying that all treatments are to be halted.
In your question, you express concerns that the doctors might “give up” on your husband. This is often a worry for many patients and families when the idea of withholding CPR is first mentioned by the medical staff.
It may be that these notions arise from the vocabulary that’s traditionally been used to discuss this topic. At many medical centres, the decision not to use CPR is recorded in the patient’s medical chart as a ‘DNR order’ – which is short for “Do Not Resuscitate.” DNR does have the sound of finality about it – and it’s a phrase that’s often heard on TV medical shows.
To help bring more clarity to the discussion, some hospitals have dropped the term DNR in favour of other language.
At Sunnybrook, “we have switched our terminology to ‘No-CPR,’ in part because DNR is very misunderstood and some people think it means ‘do not treat’,” says Ms. Bean.
At some other Canadian hospitals, you’ll find it called an ‘AND order’, which stands for “Allow Natural Death.”
Words are important. But whatever words are used, you can rest assured that appropriate treatments will continue even if your husband doesn’t want CPR.
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Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families. His blog, Personal Health Navigator, is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Follow Paul on Twitter @epaultaylor.
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Your writing is so informative. You talk about very important things for running condition. Technology and online services growing everyday. For those who are very willing to learn something using and trying online courses. There are many university and colleges providing online short courses which are very useful for who are in lockdown and want to learn something. IN Australia Unique College And Technology(https://uct.edu.au/) providing some short courses about Cardiopulmonary Resuscitation. After completing this course students can save many life instantly by giving CPR to the patients.
One way that Canadians can start these conversations and learn more about options is to create an Advance Care Plan. Advance care planning is a process of thinking about your future health choices and what you might want or not want. Part of that planning is choosing a Substitute Decision Maker, someone who understands your wishes and can speak for you if you cannot. You can download information, workbooks and resources (for individuals, families and health professionals) at: http://www.advancecareplanning.ca
Hi Paul,
Thank you for addressing this increasingly important issue, an area I have a particular interest in and am conducting ongoing research in how to better align our medical therapies with our patients’ expressed wishes for their medical care.
I have written previously on this topic for HealthyDebate (http://healthydebate.ca/opinions/is-your-a-la-carte-dnr-order-really-valid) during my experiences as a medical student. As my experience in medicine grows, I now believe that the best way (along with many other esteemed researchers and physicians in the field of end-of-life care) to address this discussion is to focus on “Goals of Care”, rather deciding upon DNR versus CPR.
Goals of care discussions focus on a conceptual approach to the principles of medical therapy, as opposed to the details. As a resident in Internal Medicine, I engage in these discussions on a daily basis. What I have found is that the a true understanding of CPR and its expected risks and benefits are almost impossible for patients and their families to comprehend, even after a thorough discussion about it. Without having ever experienced or observed it, how can anyone truly comprehend what the expected course of recovery (and its multitude of complications and setbacks) after a cardiac arrest looks like?
My approach is to ask patients and their families the following question: “Would you (or your loved one) prefer a course of treatment that focuses on extending life as much as possible, but with this course of treatment you might have more pain and discomfort. (“Life-Prolonging Treatment”); or would you prefer a course of treatment that focuses on relieving pain and discomfort as much as possible, but with this course of treatment you might not live as long. (“Comfort Care”).
The response to this helps guide my decisions surrounding CPR, and allows me to frame the discussion in the setting of their expressed Goals of Care, where I am able to make an informed recommendation based on their values.
Hi Kieran:
Thanks for your feedback.
You raise some very important points. In particular, any discussion about CPR should take place within the context of the patient’s overall goals of care.
When I talked to Dr. Rob Fowler, he also emphasized the importance of “the goals of care.”
As a layperson immersed in exploring end of life conundrums, CPR seems the last in a long journey of tough decisions.
Rather, Goals of Care conversations should – and could – happen long before the focus is end of life. From a family doctor’s narrative:
“He [the 88 year old patient] suffers from both congestive heart failure and renal failure. It’s a medical catch-22: when one condition is treated and gets better, the other condition gets worse. Hemodialysis would break the medical stalemate, but the patient flatly refuses it.”
Calling to mind the words of palliative doctor this Family Doc asked: “What are your goals for your care?” “How can I help you?” Doc was fully expecting his patient to say, “I’d like to see my great-granddaughter get married next spring,” or “Help me to live long enough so that my wife and I can celebrate our sixtieth wedding anniversary.”
Instead, his patient’s goal was pragmatic and practical and achievable, calling upon the services of physio and rehab: “I would like to be able to walk without falling. Falling is horrible.”
“With my patient’s challenging medical conditions commanding his caregivers’ attention, something as simple as walking is easily overlooked”.
I also think an opportunity to care is missed in ignoring or overlooking small pleasures that make up ‘living’ . From Atul Gawande’s book, ‘Being Mortal’ book, he tells of a patients criteria for staying alive:
“Well, if I’m able to eat chocolate ice cream and watch football on TV, then I’m willing to stay alive. I’m willing to go through a lot of pain if I have a shot at that.”
Focusing on life’s joys, accomplishes more than one goal: Helping turn those tough, emotionally-fraught, time-consuming, discussions into celebrations of life; Helping healthcare professionals follow their mandate: to help and to care for; Knowing what small pleasures can make a difference in life – right up to its end.
Kathy Kastner http://www.bestendings.com
Advanced Directive – A Choice made by Patient or Family in “advance”
As an emergency physician, I have not infrequently been the first to have a discussion of resuscitation with family members. As a result I have thought a lot about it and even my own decisions and those of my family. I have a clear approach that this is a choice that patients can make when they are able. But in the event of an arrest, there is no longer time for decisions or discussion. In the absence of clear directions to the contrary we “do everything.” In the ER it is usually not the patient, no longer coherent or conscious who can decide, but the family. Thus I present the problem as a choice of what they want us to do, in the event of an arrest. I present the choices to them along with the likelihood as best as I can predict, that resuscitation would work to prevent death immediately or even in the next few days.
For instance, when a young apparently healthy person has suffered a devastating cerebral hemorrhage and is not a neurosurgical candidate, I can guess an arrest may occur soon and CPR would almost certainly do nothing but delay death a few hours. And we can do that if the family so decides.
In the circumstance of a rather terminal-appearing cancer, I sometimes still seem to be the first to bring up the topic of resuscitation with patients or family. Again, I present it to the patient, as an issue of control and his/her choice about what he would want us to do in the event of an arrest. I emphasize the choice can be changed, but is made by default if nothing is recorded as an order and documented on various forms in the hospital or if 911 is called by anyone.
I have assisted patients and families in accessing and filing out the Out-of-hospital Advance Directive in Texas for EMS personnel. It is a shame to discover Advanced Directives that were not available and even that family were not cognizant of and patients get intubated and chest compression against their previously stated choice by well-meaning paramedics.
I emphasize that this one choice has nothing to do with other treatment decisions and options that they make with their primary and specialist physicians. I worry sometimes my colleagues don’t recognize this explicitly.
I think your description of Chest Compression may be a bit gruesome, especially in light of resuscitation data that it takes good, continuous chest compression until defibrillation if indicated to actually succeed in any resuscitation. That rather stacks the deck for an actual choice. But I have quoted the concept that almost everybody recovers on TV but in the hospital, the percentages who survive are much lower when the primary problem is not the heart or electrolytes.
I think this approach as a choice made in advance should make it much easier for primary care physicians to bring up the subject and help patients decide and create the documents necessary to carry out their choices about resuscitation. It made it easier for me to have these discussions in the ER.