CPR discussions and decisions: a necessary part of medical treatment planning
A blog post written by Dr Barbara Hayes, Clinical Lead - Advance Care Planning and Palliative Care Consultant, Northern Health (Melbourne)
Like all treatment, CPR (Cardiopulmonary Resuscitation) has both potential benefits and harms. Chest compressions and assisted breathing maintain circulation and oxygenation, particularly of the brain and heart, while attempting to restart the heart with an electric shock using a defibrillator.
Saving a person’s life is the benefit aimed for when providing CPR but not everyone would want their life saved. The current medical application of CPR captures within its net patients who have a relatively good chance of responding to CPR and those who don’t. Dying patients, for whom cessation of a heartbeat and breathing is the sign of their death, can also be inappropriately diagnosed as having a cardiac arrest, with a treatment of CPR. The life that is saved may also not be the same life the person had prior to cardiac arrest.
When cardiac arrest occurs there is no time to ponder the pros and cons of CPR, or to discuss this with the person’s substitute medical treatment decision-maker. If there is no clear instruction to withhold CPR, then the treatment is initiated. Any planning about whether or not to initiate CPR must necessarily occur prior to cardiac arrest. Admission to hospital is a common time for these discussions. However, we know that such discussions are difficult for patients, families and doctors.
Discussions about CPR are difficult because they confront the person with death. Many other treatments can be discussed without directly discussing death, but not CPR. Patients and families may be unaware that there is a third outcome option – a life that is not wanted due to further impairment, such as hypoxic brain damage. CPR discussions are also discussions about how we might die: gently, but suddenly, as a result of untreated cardiac arrest; or dying despite the intervention of CPR, either during CPR, or a short time later.
CPR discussions often occur at a time of acute illness, when the patient, or their substitute medical treatment decision-maker is scared, tired, upset, and not in their best thinking space. It requires considerable trust in the clinician and their judgement.
An article published from my PhD thesis describes a ‘Clinical model for ethical cardiopulmonary resuscitation decision making’. [1] This describes four patient categories and four different discussions about CPR. It should be noted that when a patient is dying, the discussion needs to be about the potential for death to occur suddenly, without warning, which is a very gentle way for the person to die, even if it is a shock to the family. Cardiac arrest and CPR do not need specific discussion if this scenario is understood and accepted.
Education is provided to doctors about discussing CPR, taking account of what is medically feasible and the patient’s preferences within the limits of those possibilities. However, there is little information specifically for the general public to help them understand why these discussions are often raised. Without that understanding, it may seem quite harsh and uncaring to talk about CPR and withholding CPR, and yet we know patients want to be involved in their own health decisions. Reconciling the need to avoid the harm of unwanted, or non-beneficial, CPR whilst not upsetting the patient can be challenging. Beginning the discussion at an earlier time, before a health crisis, can help people prepare. Advance Care Planning discussions and documents are a way to do this. Information can be found at Advance Care Planning Australia.
We have also recently released an animated black-and-white film, ‘The Inappropriate Question’ specifically aimed at the general public, to help people better understand why a CPR discussion might arise in hospital. It aims to discuss this serious topic in a non-emotive way with some gentle humour. The film was a collaboration between: Northern Health Advance Care Planning Program; Geriatrician, Professor Joe Ibrahim and his colleagues who have made other Prof Joe films in the same style; and the Victorian Department of Health and Human Services who provided funding.
It is hoped that greater awareness of CPR decision-making prior to acute illness and hospital admission may result in these discussions being less confronting, less upsetting and more considered. The person’s preferences or advance care planning can then be incorporated into a medical treatment CPR plan should cardiac arrest occur.
References
- Hayes B. Clinical model for ethical cardiopulmonary resuscitation decision-making. Intern Med J. 2013 Jan;43(1):77-83. doi: 10.1111/j.1445-5994.2012.02841.x.
Dr Barbara Hayes, Clinical Lead – Advance Care Planning and Palliative Care Consultant at Northern Health (Melbourne)
This blog is part of series of blogs commissioned by ELDAC to support aged care health professionals and care providers in providing end of life care. You can find more information on the ELDAC website. Additionally, the ELDAC Helpline is available 9am – 5pm, Monday – Friday (CST) on 1800 870 155 or email at ELDAC.Helpline@flinders.edu.au