“Maggie would have wanted everything done. She didn’t want to die.”
I’m sitting beside *Maggie’s hospital bed, speaking to her sister, her only surviving next of kin and substitute decision maker. I have known Maggie for over six months. When she was first referred to see me, she was a dynamic 45-year-old woman who had just been diagnosed with metastatic pancreatic cancer. Through multiple discussions we had over the following months, Maggie was very emotional when talking about the incurability of her disease and didn’t want to discuss its eventual outcome—it was simply too heart wrenching. Now in hospital, her health had declined quickly. Many of the physicians she encountered asked about her wishes regarding CPR. Consistently and with a scared look in her eyes, Maggie told them, “Please do everything to keep me alive.”
Today, sitting at her side, I try to speak to Maggie, but she is slipping in and out of consciousness. Feeling helpless, I envision the overhead system blaring “CODE BLUE, CODE BLUE,” and the ICU team rushing over to perform CPR. If Maggie survives the ordeal, she will end up on life-support machines, not able to eat, speak, or breathe independently, and she will have an extremely low chance of being able to make it out of hospital. I wonder: Is this the life Maggie would have wanted? Did she actually understand what would happen if “everything” was done to keep her alive?
As a palliative care physician, my practice routinely involves assessing patients with incurable illnesses and discussing future treatment plans, including whether they wish to receive CPR or not at the end of life. For those who say they want it (and for those who don’t say they don’t), CPR must be performed, regardless of how much harm their physicians think it may cause.
Since 2016, the College of Physicians and Surgeons of Ontario, the regulatory body for physicians, has mandated that physicians cannot write “do not resuscitate” as an order on a patient’s chart; if they think a DNR is best, they must obtain permission from the patient or their substitute decision maker. The same is not true of other potentially life-saving treatments such as dialysis, chemotherapy, or surgery. If a physician feels these treatments present serious risks or may be ineffective, they can refuse to provide them. Sometimes patients themselves refuse these life-prolonging treatments, and still receive CPR. This is a situation which may seem incongruous to many health care providers.
Many years ago, at the start of medical school, I was taught “primum non nocere,” meaning “first, do no harm.” It is a principle I try to uphold in all patient encounters. At the same time, our medical system is founded on patient choice and autonomy. As health care providers, we always discuss current and future treatments with patients so they can make decisions congruent with their wishes and beliefs. But what do we do when it seems impossible to hold up both principles? Should we be forced to provide treatments as aggressive as CPR, knowing that they may cause more harm and suffering?
In a 2006 Canadian study of elderly hospitalized patients with incurable illness, only two percent could name the four treatments that are performed on patients during CPR: chest compressions, defibrillation, intubation, and medications. Hollywood often provides storylines of miraculous recovery post-CPR, usually in a young person who is the victim of some type of trauma such as an accident, shooting, or drowning. What isn’t shown is the brutal cruelty of a progressive decline in appetite, mobility, and muscle mass that accompany a terminal illness such as metastatic cancer or dementia. After CPR, few patients (about one out of eight) survive to be discharged from hospital, and among those who do, many do not recover their previous level of functioning, often needing to be transferred to complex continuing care facilities that can support artificial breathing or feeding. For elderly patients who have an unwitnessed arrest outside of hospital, making it out of hospital is even more unlikely—one recent study showed one survivor out of 202 in the 80–89 age group, and none among those older than 90. CPR is often not effective, so should it be designated as the default treatment?
While there is no simple answer to this complex issue, some of the conflict surrounding CPR could potentially be mitigated by better communication. Health care providers often do not have much training or experience with difficult conversations. When patients and their families request CPR, doctors sometimes respond with implicit or even explicit bias, leading to conflict and mistrust. Cultural and religious factors often play a major role in influencing patient decision making, and our biomedical model of health care does a very poor job of acknowledging and addressing these issues. Furthermore, many Canadians are not aware of and do not participate in advance care planning, a process by which anyone, at any age, can document their wishes for future health care, including their wishes for or against resuscitation at end-of-life.
As our health care system struggles to accommodate our aging population, discussions about CPR will only become more important and relevant. Health care teams should move from “doing everything” to doing everything appropriate that is in line with the wishes and beliefs of the patient. We must work toward developing better communication skills in health care providers so that patients and family members do not face bias or discrimination at one of the most difficult times in their lives. Some patients will always opt for CPR, and their wishes should be respected.
But at the macro level, we need to correct public misperceptions about CPR. Over the last 30–40 years, we have had ongoing public health campaigns promoting healthy eating and exercise, prevention of sexually transmitted infections, and smoking cessation. For decades, our society has followed the “rule of rescue,” an imperative to always save endangered lives, regardless of cost. CPR classes have been widely available to the public, and we find defibrillators in our malls, hockey rinks and university campuses. But why not also have a public health campaign to discuss the harms of CPR in patients with terminal illness, which may prevent unintended suffering at end-of-life? Patients and families deserve to know the reality of this treatment, so that when the time comes, they can make a truly informed decision.
*The patient described in this story is a composite of several the author has worked with, and does not reflect a specific individual.
The author of this article is grateful for the feedback and guidance provided by two of his colleagues, Dr. Paula Chidwick (Director of Research & Corporate Ethics, William Osler Health System) and Dr. Amanda Rosenblum (Palliative Care Physician, William Osler Health System).