Matters of life and death: the challenge of CPR decision making

How can we improve patient involvement in this complex process?

MJA 1998; 169: 124-125  

Since its introduction in the 1960s and subsequent widespread dissemination, cardiopulmonary resuscitation (CPR) has saved the lives of many who would otherwise have perished. Today, whenever a patient's heart stops beating, carers are faced with an extraordinary choice. Either they may do nothing and allow the patient to die, or they may use CPR and try to breathe life back into the dying individual. How should this choice be made? Over the past 20 years numerous studies have sought opinions on this dilemma. In this issue of the Journal Kerridge et al report on the first Australian survey into the attitudes of hospital inpatients and staff.1 The authors used a simple cross-sectional design to quiz both patients and healthcare professionals at Newcastle's John Hunter Hospital. They sought attitudes on a range of matters concerning CPR and the decision-making processes that surround its use. Despite the study's shortcomings, such as relatively low response rates and the treatment of the study population as homogeneous, the results contain some interesting and apparently paradoxical findings. Although a large proportion of both patients and healthcare professionals felt that doctors should always ask patients whether they would like CPR, only a very small percentage of patients had actually discussed CPR with their doctors. This perplexing result mirrors the findings of international studies that surveyed far sicker inpatient samples. In two studies, Bedell and co-workers examined patients in Boston who had either required CPR or had been the recipients of do-not-resuscitate orders. Only about 20% of these patients had been involved in their own CPR decisions.2,3 Why is CPR decision making such a difficult issue, and what could be done to improve matters? The hardest thing about CPR decision making is the timing of the decision. Obviously, at the moment a patient requires CPR, he or she is unable to declare a preference about whether resuscitation should occur. Furthermore, patients usually lose their ability to consider CPR options well before the procedure is needed. Only about 20% of patients are competent at the time a do-not-resuscitate order is considered.3,4 Consequently, any patient input into the decision making process must be taken well before the final decision is needed. The patient must declare a position in advance. However, gaining a patient's preferences about CPR, and documenting them, is complicated by a series of other problems. Firstly, the details of advanced CPR and its efficacy are poorly understood by the general public. Providing patients with sufficient information to allow an informed decision is difficult and time consuming. It seems extremely unlikely that any simple method of seeking CPR preferences (upon, say, a patient's admission to hospital) would yield either valid or usable data.5 Secondly, advanced CPR involves a multitude of procedures and many patients may be willing to undergo some of these but not others.6 CPR decisions are not simple "yes or no" choices. Thirdly, although we know that likelihood of survival influences patients' preferences about CPR, it is often difficult to make predictions on the likelihood of benefit for any individual patient.5,7 These predictions become more difficult the longer the period between the prediction and the resuscitation. Fourthly, although people are inclined to believe that they can accurately predict whether they would want CPR in some future situation, this may not be the case. Weighing up risks and benefits hypothetically is quite different to weighing them up in reality. A number of lines of evidence suggest that, in general, the sicker people become the more likely they are to opt for intervention.8 Finally, although there is good evidence that patients find discussion of CPR neither cruel nor insensitive, discussions about death are frequently upsetting for patients and for their doctors.4 When there is no pressure for a CPR decision, it is no surprise that both patients and their doctors are disinclined to bring the matter up. In the face of so many obstacles, how are we to proceed? While guidelines, legislative initiatives, and targeted interventions may all have a role in improving the way CPR decisions are made, there are no simple answers to this dilemma. Generally, patient preferences about CPR must be the most important ingredients in CPR decision making, but these are hard to obtain and may not always be valid in a given situation. Even if one knows the patient's preferences, there can be no doubt that the complex nature of the factors that surround a decision to resuscitate will, on occasion, justify taking a course apparently contrary to the patient's wishes. The best CPR decisions will follow preparations that began long before the patient's heart was stilled. They will involve considered consultation with the patient, family and other healthcare professionals. They will require examination of the evidence relevant to the patient's predicament and they will rest on careful deliberation of all the issues of concern to that patient on that day. They will call forth the finest compassion but, for all of this, they will often fall short of a perfect result. Put simply, the best CPR decisions will involve the best clinical care, and providing that is the challenge for us all. Christopher J Ryan Consultation-Liaison Psychiatrist, University of Sydney, and Department of Psychiatry, Westmead Hospital, Westmead, NSW Kerridge I, Pearson S-A, Rolfe IE, Lowe M. Decision making in CPR: attitudes of hospital patients and healthcare professionals. Med J Aust 1998; 169: 128-131. Bedell SE, Delbanco TL. Choices about cardiopulmonary resuscitation in the hospital. When do physicians talk with patients? N Engl J Med 1984; 310: 1089-1093. Bedell SE, Pelle D, Maher PL, Cleary PD. Do-not-resuscitate orders for critically ill patients in the hospital. How are they used and what is their impact? JAMA 1986; 256: 233-237. Stolman CJ, Gregory OJ, Dunn D, et al. Evaluation of patient, physician, nurse and family attitudes toward do not resuscitate orders. Arch Intern Med 1990; 150: 653-658. Murphy DJ, Burrows D, Santilli S, et al. The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation. N Engl J Med 1994; 330: 545-549. Youngner SJ. Do not resuscitate orders: no longer a secret, but still a problem. Hastings Centre Report 1987; 18: 24-33. Frankl D, Oye RK, Bellamy P. Attitudes of hospitalised patients toward life support: a survey of 200 inpatients. Am J Med 1989; 86: 645-648. Ryan CJ. Betting your life: an argument against certain advance directives. J Med Ethics 1996; 22: 95-99.