Resuscitation

Dr Abbie Flinders

Specialist Registrar – Care of the Elderly

2007

To care, to control, to comfort

Introduction

Emotive subject Own ideas, thoughts and expectations Many opportunities for miscommunication Ethical dilemmas Needs a rational and guideline based approach

To begin discussing this topic we need to ensure all concerned understand

What CPR is And…. What it is not

CPR is…

External chest compressions Artificial respiration Defibrillation

CPR is not…

Investigation or treatment of reversible conditions Analgesia Antibiotics Any drug for symptom control Feeding or hydration Suctioning Seizure control Treatment of choking

Why do we need to think about CPR or to make advanced decisions?

Why has there been an increased focus on CPR decision making in recent years?

Medicine has changed

People survive acute illnesses they previously would not have.

Medical intervention is keeping people with chronic disease alive for longer.

People with cancer receive drugs not for cure but to increase quality and often length of life.

Basic medical ethical principles

To do good To do no harm Respect autonomy Justice

To do good…

Our aim is to restore or maintain health. Is CPR therefore beneficial as it prolongs life?

Doing harm…

Prolonging suffering?– For person receiving/surviving CPR– For families

Success rates of 15% shown in large studies

Diminishing quality of life?– At least 2/3 of out of hospital cardiac arrests have

new neurological or functional problems

Respecting autonomy

Our role is to give information and guidance to help people make choices.

Need to identify people who would choose not to undergo CPR

Is CPR a viable option at all? We cannot ask opinion on a treatment option

that is not available

Justice…

Non-discriminance

Making the best of available resources

Human Rights Act

Article 2 – the right to life

Article 3 – to be free from inhuman or degrading treatment

Article 8 – to respect privacy and family life

Article 10 – to freedom of expression including the right to hold opinions and receive information

Article 14 – to be free from discriminatory practices in respect of these rights

How we should go about making the decisions

1) Circumstances of cardiopulmonary arrest

2) Likely clinical outcomea) Where death is expected due to underlying

disease

b) All other circumstancesUltimately the final decision lies with the most senior medical person

looking after the person – either consultant or GP.

Particular issues related to palliative care

The expanding role of palliative care

Palliative care used to be confined to terminal care

Increasing life expectancy for people with “incurable disease”

Integral part of community and hospital care (no longer confined to the hospice)

Need to distinguish who is receiving terminal care

CPR in the hospice

Previously “blanket” do not resuscitate policies Change in case mix in hospices

– Shift towards terminal care in community– Bed closures

Palliative care does not aim to prolong life but it certainly doesn’t aim to shorten it!

So is CPR ever appropriate in the context of palliative care?

Case of MWelsh hospice 2001

47 year old woman Malignant melanoma excised from leg 6 months later – chemotherapy for liver

metastasis Vertebral metastases leading to spinal cord

compression– Radiotherapy– Hospice admission for neuropathic pain

Intrathecal opioid infusion arranged During procedure

– Apnoeic– Bradycardic – pulse 4 bpm– BP unrecordable

CPR commenced + atropine + adr Transferred to acute hospital

Spontaneous circulation recovered after 5 mins Spontaneous respiration after 50 mins Transferred back to hospice 48hrs later Died two weeks later Had time to put affairs in order She and family felt correct decision had been

made

In the hospital

Increasing numbers of palliative and terminal care patients admitted to acute hospitals

Reluctance to make decisions Night and weekend admissions with little

information on long term condition

Mr X

Metastatic pancreatic cancer Living at home with family support Sent in by GP for exclusion of DVT On arrival – 10pm due to ambulance delays

– Hypotensive– Drowsy– Clinical DVT

Entering terminal phase Is there anything reversible? Had he been deteriorating in recent days/hrs GP sent in for exclusion/treatment of DVT,

what does this suggest? CPR decision needed asap!

These types of situation are extremely stressful for the teams and families

looking after the person and should be avoidable

A word on communication

30% of doctors feel uncomfortable discussing CPR with patients (Stolman et al)

Yet this is one of the most important parts of the decision making process

What do patients and relatives think?

Morgan et al studied views of elderly patient and their relatives

Mean age was 80 Most (98%) did not feel uncomfortable discussing their

own CPR status and in fact welcomed it 25 out of the 87 people who did not already have a not

for CPR order in place, requested one

Advance directives & Living wills

Formal way to document wished regarding future treatment

No statutory legislation covering them, they are upheld by common law

Usually involve decisions re CPR, antibiotics, surgery, ITU care and ventilation

May not contain statements regarding:

1. Illegal acts such as euthanasia

2. Demanding treatment contrary to the clinical judgement of the medical team

3. Refusal of food or drink by mouth

4. Refusal of measures or treatment designed solely for comfort e.g. analgesia

Summary

Extremely complex and emotive subject Increasingly important to encourage open discussions,

transparent decision making Ensure written and verbal information available to all Ethical principles at the forefront of decision making to

concentrate on providing CPR to the correct cohort of patients and ensuring a good death for as many people as possible

Thank you