As we age, we are faced with some tough decisions regarding what “heroic” measures to take in the event our heart should stop, we are no longer able to breathe on our own, we cannot consume food orally, etc. Would we want to be kept alive artificially (i.e., ventilator-dependent), do we want “everything done” or would we choose to stop treatment up to and including a Do Not Resuscitate (DNR) order. These are questions often asked when someone arrives in an emergency department, someone under a lot of stress, possibly actively dying, and yet we are required to ask these questions.
I read an interesting article in Medscape Nurses on the subject of “when to offer CPR”. The article talked about an 83-year-old man who was found unresponsive after 10 days alone, transported to the emergency room and because there were no advance directives on file, he was considered a full-code. About 10 years ago, a group of physicians from several medical centers and medical schools proposed changes to how we determine resuscitation status. They suggested three distinct approaches:
- Consider CPR when the benefits vs risks are uncertain, and the patient is not end-stage;
- Recommend against CPR when there is a low likelihood of benefit and high likelihood of harm (i.e., patients with anoxic brain injury, advanced incurable cancer, or end-stage multiorgan dysfunction);
- Do not offer CPR to patients who will die imminently and have no chance of surviving CPR (i.e., patients with multiorgan dysfunction, increasing pressor requirements, and those who are actively dying without a single immediately reversible cause).
Hmm, seems reasonable right? Sometimes, the end doesn’t justify the means both from a medical and ethical standpoint. Sadly, we often see CPR being performed on patients who would not fall into category #1 above. Sure, it isn’t usually our decision to make, however, ethically, are we having these frank discussions with our families and their loved ones. It might be time to initiate an ethics committee in your center and focus on this topic. Involve your physicians in educating families and residents BEFORE the question needs to be asked. Remember, first do no harm and the rest will follow. Stay the course, stay informed and stay well!