When CPR causes harm and suffering


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14 comments

  1. Patti Staples

    Great article. In my 38 years of nursing, I found many more “futile” interventions being done for individuals who “want to live” and they request that “everything be done”. Who doesn’t want to live? However, many people have no idea what it can mean to have “everything done”. They also don’t know how likely it is that they will be the same functionally after a resuscitation. Unfortunately we often know when resuscitation is likely to be futile but still we do it. I agree that a public health campaign is needed. Advance care planning discussions need to happen as part of routine primary health care.

    • Amit Arya

      Thank you so much for your comments, completely agree!

  2. Martin R Chasen

    Superb article Dr Arya
    You have described this form of treatment with insight, empathy and compassion.
    The debate should be brought forward to the public domain, so that the public can be aware of the difficulties physicians face, where on the one hand we are forced to treat patients to keep them alive and on the other hand we may be forced to adhere to a MAID request and-or be instruments in facilitating their death.
    How to steer through this maze and conflict requires lots of team support and encouragement and debriefing
    In the patients best interests remains an elusive ideal.

    • Amit Arya

      Thank you very much Dr. Chasen for your kind words of encouragement. I completely agree that some of the situations we commonly face are undoubtedly complex, requiring teamwork, clinical expertise and empathetic communication skills. Situations may arise where it may be challenging to balance our primary ethical duty, which is to “do no harm,” with patient autonomy.

  3. Jeffrey Brooks

    So insightful. Yes I have read where CPR is successful 66% of the time on television. Maybe 10% in real life. Sure if a 25 y.o. hockey player goes into cardiac arrest at the rink, yes CPR, AED. Simple decision.
    If 85 y.o. grandfather suffering from multiple afflictions goes into cardiac arrest, it might be a simple decision on its own. Yes it helps if the person and their SDM are realistic and agree DNR.
    What is sad is when people bring in religious beliefs which to me can be reverse slippery slope. We keep a person alive just because we can. Not because they could have longer quality life. BTW CPR is not mentioned in the Bible. So there is no religious basis for doing CPR or not.

    The author suggests more education for clinicians. More work, more responsibility. I feel there is more need for the public to educate themselves about EOL and options. I was a palliative care volunteer for 8 years. Our hope was people at that stage accepted death. No they didn’t lose their battle so valiantly fought. No they didn’t give up! To me that is the challenge. Educate the public.

    • Amit Arya

      I agree with you that public education is a priority- in fact I feel strongly that a public health campaign to provide education about CPR outcomes in the context of terminal illness should respectfully take into account cultural and religious preferences. Furthermore, I would like to add that the health care community also has work to do to educate itself- you may be surprised to also learn that many physicians are not trained in prognostication, and some are still not aware about the poor outcomes after aggressive end-of-life treatments (such as CPR) in advanced life-limiting illness.

  4. Richard Gould

    I remember a situation like this many years ago when I was a resident. An arrest was called for a 90 something old women who was in the terminal stages of metastatic ca. Unfortunately there was no information about the wishes of the woman or her family in regard to resuscitation. So the attempted resuscitation was begun but with little evidence of success. Thankfully the attempt was called off after a short interval. I remember one of the nurses on the team who objected to the termination of the resuscitation effort. All I could think of was that I hoped that my mother would never endure such an end to her life. And fortunately she made it clear in advance that this was not what she wanted.

    • Amit Arya

      It is definitely a most unfortunate situation, raising many ethical dilemmas. Most definitely as you imply it is ideal for a patient to discuss their own wishes prior to end-of-life. But in an elderly patient with terminal illness, should CPR be the default? I am reminded of a case from the UK where a nurse did not perform CPR on an elderly patient, in spite of no documented pre-determined wish for “no CPR” from the patient or her SDM. Unfortunately, the nurse was found guilty of professional misconduct- even though the son was happy his mother did not receive CPR at end-of-life.

      https://blogs.bmj.com/bmj/2019/03/19/james-davies-cpr-for-all-a-case-of-dr-jekyll-and-mr-hyde/

  5. Paul Anderson

    An incident occurred while a family member was in hospital in 2013, resulting in her transfer to Intensive Care. Although she had been interviewed twice concerning her wishes in regard to medical intervention since her admission to hospital, instead of immediately initiating the aggressive intervention that she had specifically asked for (twice verbally and once in a written legal document that the hospital had on file) the ICU team called her POA to ask him to authorize a DNR order.

    The hospital’s delay in initiating the aggressive therapy requested may have contributed to the brain injury the patient suffered as a result of insufficient oxygen supply.

    For 10 days following her transfer to the ICU, the team continued to pressure the POA to authorize cessation of aggressive life saving therapy and sign a DNR order. Given the existence of a legal document explicitly requesting full code, it would have been inappropriate and perhaps illegal for the POA to override the patient’s stated wishes. One team member even went so far as to knowingly misrepresent the patient’s condition in order to convince the family and the POA that the patient should simply be allowed to die.

    Again and again, very grim prognosis scenarios were outlined in the hope that the POA would ignore the patient’s wishes and authorize the ICU team to let her die. Quality of life was often the theme in the ICU team’s pressure tactics. The patient would likely remain in a vegetative state indefinitely (within a few days she was awake and communicative). The patient was ventilator dependent and would never breathe on her own again (10 days later she was breathing on her own). The patient would forever have to remain in an institutional setting; she could never go home again (within 6 months the patient went home to stay with family; within a year she was again living independently).

    While it is understandable that the medical staff would have had serious reservations about providing aggressive life saving therapy in this case, the fact is that the prognosis offered was repeatedly inaccurate. Had the POA set aside the patient’s wishes and authorized cessation of the aggressive life saving therapy explicitly requested by the patient, a life would have been needlessly lost.

    I agree that it is very important for patients and their substitute decision makers and POA’s to be well aware of the realities and risks involved in aggressive life saving techniques such as CPR when deciding upon the patient’s wishes in this regard. Physicians should also plan ahead in regard to what they will do when a patient’s legally supported wishes in regard to aggressive life saving therapies conflict with what the physician considers to be medically appropriate. The rights of both physicians and patients must be respected.

    • Amit Arya

      Thank you for sharing this inspiring story of perseverance- can’t imagine what the POA of the patient must have gone through at the time, and most definitely they deserve a lot of credit for adhering to the patient’s pre-expressed wishes. I agree with you- planning ahead is key so that a collaborative discussion can occur between all parties to balance patient and physician wishes.

  6. Sue Jones

    Great article! As Respiratory Therapist with over 35 years of working in the ICU environment I have come to learn that people think we are going to let them suffer if they agree to a DNR. I totally agree we need more public education on the harm of CPR and what it means to die without pain. Dying naturally doesn’t need to be painful.

    • Amit Arya

      Thanks for your feedback, I agree with you completely! A term like “do-not-resuscitate,” stated in the negative, can also be mistaken for “do not treat.” It may be better to change the wording to “allow natural death” or “AND” which has a more positive connotation.

  7. kathy kastner (@KathyKastner)

    Great article great points Dr Arya. Oh to have conversations that don’t focus on CPR/DNR but rather the practical, quality of life activities-of-daily-living that may be permanently affected by treatments/procedures – yes, even those that the surgeon, nephrologist or oncologist may recommend. To your point, CPR aside, after aggressive treatments of the seriously ill “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”

    • Amit Arya

      A great point Kathy! I hope one day our health care system and the people who work in it will have sufficient resources to have better conversations about future quality of life & functioning- as well as integrating a palliative care approach early in the disease trajectory, rather than at end-of-life! 🙂

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