CARDIOPULMONARY resuscitation (CPR) is a violent activity. Many of those subjected to CPR suffer multiple broken bones or severe internal injuries. For otherwise healthy people who experience a heart attack or an accident, the benefits can outweigh the risks. However, for patients who are dying from life-ending and irreversible illnesses, or have chosen not to have their life prolonged, CPR offers no benefit.
Recently, I heard a doctor speak about the death of his grandmother, who lived in an aged care facility. Nursing staff had called for an ambulance after she deteriorated rapidly. When the paramedics arrived, they found that the woman’s heart had stopped. They believed that they had a duty to start CPR because nobody could produce a valid order not to do so.
Her choice that her life not be prolonged was supported by her family and had been documented in the notes by her GP. However, no written instruction regarding resuscitation was immediately available. After a prolonged period of unwanted and pointless resuscitation, the GP was eventually contacted and ordered that CPR be stopped.
Too often (and yet again last week from another colleague) I hear woeful tales of similar assaults, usually, but not always, on elderly people. One frail older woman who rang “000” when her demented husband collapsed and died was told she must commence CPR pending the arrival of the ambulance.
Some years ago, I too was part of a similar event. We had thought that we had prepared our patient and their family well for a peaceful death at home. Unfortunately, our patient collapsed suddenly and died in the toilet. The family, understandably, called for help from emergency services, who chopped through the door and started CPR because we had not provided a written order not to do so.
CPR shatters the peace of an expected death, destroying what might have been a time of intimacy and tranquillity. While patients cannot report their experience, families and health workers are often hugely distressed by their memories of the death, and may feel guilty that they could not protect the dead person from the onslaught.
About 440 people die every day in Australia. Given the frequency of the stories, I would not be at all surprised if pointless resuscitation were a daily occurrence in our country. The performance of CPR often causes grievous bodily harm – defined in Section 1 of the Queensland Criminal Code as “any bodily injury of such a nature that, if left untreated, would endanger or be likely to endanger life, or cause or be likely to cause permanent injury to health” – and would feature in news bulletins every day were it not being undertaken by health workers as our perceived duty, sometimes at the request of family members, and fulfilling a community expectation.
So how is it that a frail elderly person who has expressed their choice to die peacefully can be subjected to a violent assault that transforms their dying into a miserable, medicalised and undignified nightmare for the participants? Why, after a prolonged period when no effort had been made to slow their decline, are patients suddenly attacked by health workers, or even their own family, when, as expected, their heart stops?
I think these occasions are depressingly common because we have yet to fully rediscover that the job description for doctors includes a particular duty of care to people at the end of their life.
This duty of care holds us generally responsible for integrating into our practice the reality that there comes a time for everyone when further treatment cannot cure our ills or will not help us to a better quality of life.
The complexity of modern medicine leaves us with no choice other than to communicate openly with our patients with life-limiting illnesses so that they can understand the choices we are offering and their realistically achievable outcomes. Failure to do so robs people of the opportunity to decide how to best spend the finite resource of their time in pursuit of their hopes and goals.
As a profession, we can help to ensure that the documents available for Advance Care Planning (ACP) fulfil the complementary needs of patients, their families and clinicians, and that the law in this area supports good medical practice. We can also try to ensure that our health systems use documents effectively, including harmonising ACP across Australia.
As individual clinicians we can encourage and support our patients (and the community generally) to treat dying as a subject for open discussion and appropriate preparation.
And when helping a person with a life-limiting illness and their family to prepare for dying, we must nurture an understanding of the limits of life-prolongation. For example, I explain why we do not offer CPR at the end of life by saying:
“When we die from a progressive illness, our heart stops because we are dying, we don’t die because our heart stops”
“Having accepted that a person is dying, it would be irrational to do CPR when the heart stops if we (the patient or their family and the doctor) have decided not to do anything to prevent them from reaching that point”
Patients’ plans for their care at the end of their life can remain unrealised unless doctors create documents that provide clear treatment instructions. Ever since my patient’s door was smashed down, I have tried to ensure that all my patients who are dying, and their families and carers, have available (and know how to use) written doctor’s orders regarding CPR.
Queensland’s doctors can complete an Acute Resuscitation Plan (ARP), which instructs other health workers regarding the scope of treatment (including CPR) that a patient should or should not receive in the event of an acute emergency. Centres that have embraced the ARP (e.g., over 90% of patients who die have an ARP) have found it to be a catalyst for discussion and effective as a means of reducing the risk of unwanted intervention.
We doctors have the duty and the authority to prevent the harm of futile CPR on our patients (other people’s grandmas, grandpas, spouses, siblings and children) when we know they are dying. Avoiding inappropriate resuscitation is our responsibility.
Associate Professor Will Cairns is a palliative medicine specialist based in Townsville and author of the eBook Death Rules – how death shapes life on earth, and what it means for us.
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