You have a right to say “No” to CPR. And you may want to.

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  • Nanci Corrigan says:

    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:

  • Kieran Quinn says:

    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 ( 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.

    • Paul Taylor says:

      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.”

    • kathy kastner says:

      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

  • Kirt Walker, MD, FAAEM says:

    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.


Paul Taylor


Paul Taylor is a health journalist and former Patient Navigation Advisor at Sunnybrook Health Sciences Centre, where he provided advice and answered questions from patients and their families. Paul will continue to write occasional columns for Healthy Debate.

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