Doctors should limit CPR use when inappropriate
Patient’s insistence can be detrimental to staff
Rita T. Layson, MD, MA, professor of medicine at the University of North Carolina at Greensboro, was at an all-day seminar on death and dying when she began sobbing uncontrollably. "All of a sudden I realized that I had been carrying around a gunnysack of anger, despair, and frustration inside of me."
During a "guided imagery" exercise, Layson had imagined herself doing one of many cardiopulmonary resuscitations (CPR) as a resident physician. The feelings she experienced came from years of performing codes on patients who were close to death while thinking, "What am I doing to this patient?" Layson says residents often feel that certain patients should be allowed to die, but they are required to perform CPR despite its almost certain futility.
Doctors and other health care professionals suffer tremendous anxiety when they participate in futile resuscitation of patients, say Layson and others. Unlimited use of CPR raises ethical considerations that are sometimes lost in the myriad issues surrounding end-of-life care. But Layson says it is time to answer the primary problem with futile CPR use potentially severe emotional harm to the caregiver. She passionately argues that it is time to change the practice of always performing resuscitation when a patient arrests, even when the patient has not consented to a do-not-resuscitate (DNR) order.
"Nurses who have nurtured and cared for a patient must now mark the patient’s death by performing CPR and feeling ribs crack under their hands. Residents and other physicians must order violent acts in an unsuccessful attempt to prolong life," she says. "This is surely undesirable if we want health care providers to be caring, sensitive people."1
Generally these futile attempts at saving a patient’s life occur because the patient or family member has not consented to a DNR order. The common response for an ethics committee or consult team is to suggest that if a physician deems a DNR order appropriate, but the patient or decision maker does not agree, the patient should be transferred to another service or physician as soon as possible.
Layson and others contend it is time to recognize that this approach simply does not work. "I’m not sure there are the right alignment of incentives to back up the ethics of these situations," argues Lance Stell, PhD, director of the ethics consult service and ethics committee vice chair at Carolinas Medical Center in Lexington, NC. "We need a cultural change," he says.
Developing a futility policy can help
"No one denies that a DNR order is a legitimate way to handle these situations, but getting the patient’s consent isn’t always the most reasonable approach," Stell maintains. "You have to develop procedural safeguards that encourage physicians to do what they think is right."
Stell coordinated the development of the hospital’s futility policy six years ago but notes the policy has never been used to write a DNR order without patient consent. Good futility policies help allay physician fears about legal risk, but they often have limited benefit in clinical practice.
"Such policies are helpful because they stand as a symbol to physicians that they don’t have to do everything, that there are limits," he says. "But these policies are usually so complex that the patient dies before the ethical dilemma is resolved."
Futility policies should never be used in the absence of a process that helps physicians, patients, and family members make decisions, ethics experts caution. Rather, they should help your institution begin a dialogue on where to draw the line on some end-of-life treatments and help determine if and when exceptions should be made to shared decision making between patients and their physicians.
Layson and Stell urge physicians and other ethics committee members to review their futility policies and the practice of obtaining DNR orders. Ask these questions: "What do we consider a successful code’? returning a rhythm for 24 or 48 hours, or allowing the patient to awaken and have a meaningful life," says Layson. "How do we ask the patient or family member about a code?"
A recent study of patients who had received cardiac resuscitation gave one hospital ethics committee member insight into how to approach other patients. "We asked patients what their resuscitation experience was like and what would have helped them make the consent decision," says D. Gay Moldow, BSN, MSW, LCSW, a social worker and ethics committee co-chairperson at the Veterans Affairs Medical Center in Minneapolis.
"Many patients told us they would have welcomed more in-depth conversations with their doctor before they became ill," she says. Patients want to be asked about their general wishes before they get into a specific "yes" and "no" list of treatment choices.
When it comes to resuscitation, most patients said they need more information about the procedure, how it works, what happens, and how successful it is. This information would help them make a decision, they reported.
In response to these patient comments, Moldow developed a draft "DNR card," a two-sided tool for professionals. The front contains suggestions for how to phrase the consent question and when and where to ask the patient. The back includes a definition of resuscitation and statistics on its effectiveness.
Layson cautions that the phrasing of the informed consent question is critical, and Moldow agrees wholeheartedly. Layson says, "Don’t ask, Do you want us to do everything we can to save the patient’s life?’ Who would ever say, No’?"
Add CPR to living will discussions
"We found that the health care professional is far more uncomfortable bringing up the idea," says Moldow. "Put CPR in the context of advance planning, as part of a discussion about the patient’s living will," she suggests. Moldow says many patients want to talk about their wishes. "Physicians shouldn’t assume that bringing up the question of CPR makes the patient think you are trying to kill them," she says.
Good planning will alleviate some problems with DNR orders and patient consent, Stell says. He urges committees to implement guidelines on consent for DNR orders that give patients or family members time to decide whether resuscitation might be appropriate for them. Ask several times, he urges. "The first opinion isn’t necessarily the final answer."
Stell and Moldow contend that spending this additional time with a patients and/or family members helps your institution see its ethical values incorporated into daily clinical practice.
Although careful planning can help, Layson advises physicians and ethics committee members to put each case in context and to handle situations on a case-by-case basis with input from the institutional ethics committee.
In some circumstances, a physician may feel obligated to write a unilateral DNR order to protect the patient, the patient’s family, and the staff from harm, she contends.
In situations where the patients are aware during resuscitation, they probably suffer a great deal. Family members miss the opportunity to share last moments with loved ones and may suffer increased anxiety and grief. Above all, the psychological risk to health care professionals must be considered, says Layson.
Use your ethics committee to provide a forum for nurses, residents, and other staff to express their concerns and anxiety over inappropriate codes. Encourage your attending physicians to be more supportive of residents who carry out their orders, says Stell.
Ethics committees also should look at developing futility policies jointly with other health care providers in their community, these experts say.
Reference
1. Layson RT and McConnell T. Must consent always be obtained for a do-not-resuscitate order? Arch Intern Med 1996; 156:2,617-2,620.
[Editor’s note: Moldow currently is revising the DNR card. For more information on the study or to obtain a card, contact her at (612) 725-2042.]
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