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Rapid Responses: Rapid Responses published:
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A 'blanket approach' to resuscitation might be harmful.
- Rónán Collins (13 September 2003)
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Bravo
- Elizabeth J Brierley (24 September 2003)
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What do patients want at this stage of their lives?
- Andrew Thorns (25 September 2003)
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CPR - the mother of all interventions
- W. Matthew Widdowson, KJ Madhavan (6 October 2003)
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A hairy chest protects against unwanted resuscitation.
- Phillip J. Colquitt (7 October 2003)
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Do patients want to discuss resuscitation?
- Madhumita Bhattacharyya, Chris J Gallagher (8 October 2003)
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Rónán Collins, consultant physician in Elderly Medicine Leeds General Infirmary, LS1 3EX
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Editor The recent debate on discussing CPR decisions with the terminally ill should really have been broadened to the patient population has a whole (We are afterall all terminally ill) 1. ! It has highlighted however the lack of public education regarding CPR and research into the effect of such discussions on patients. Decisions regarding resuscitation are an everyday clinical duty in elderly medicine yet they remain difficult and often contentious for doctors, nurses, patients and carers. A blanket policy of 'discussion with all'has been advocated but seems wholly inappropriate where the effect might be deleterious on patients' mental health, and where doctors have a duty of 'best interest' ( which includes not providing futile and burdensome treatments) to their patients. Certainly, in my experience, such discussions can cause anxiety even when I have felt individual patients might appreciate and cope with the discussion. It can induce a feeling of 'I must be dying' in patients who were otherwise doing well. There needs to be better public education and frank debate on the role and success of CPR, bringing the issue 'out into the open'and achieving proper consensus on guidelines. Until then including a routine ethical history as part of nursing triage on admissiion would allow those with strong opinions to voice them in a less threatening atmosphere. This at least might help us not 'terrorise' the patient population with blanket policies when they expect their physician to act in their best interest at all times. 1. Waxman J, Higginson IJ. For and against: Doctors should not discuss resuscitation with terminally ill patients. BMJ 2003;327:614-616. Competing interests: None declared |
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Elizabeth J Brierley, consultant physician, care of the elderly St Lukes Hospital, Bradford, Little Horton lane Bradford BD5 0NA
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Bravo for the thought provoking articles 'For and against resuscitation with terminally ill patiebts' BMJ 2003;37:614-618. I agree with both sides. However wouldn't this whole area be much easier if we all frankly discussed prognosis when we first knew an individuals life expectancy was reduced. I am no saint in this area but I do know that discussing 'Do not resuscitation' decisions with a person who is in the last days/weeks of life is distressing for them if they have not realized or acknowleged that death is round the corner. Discussing prognosis when death is more distant can facilitate discussion around wishes before death at a later date. Competing interests: None declared |
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Andrew Thorns, Consultant in Palliative Medicine Pilgrims Hospice, Ramsgate Road, Margate CT9 4AD
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Editor It is hard to polarise opinions on the need to discuss resuscitation with the terminally ill (1). Any such decision must take into account the broad spectrum of patient wishes and the exact stage of the “terminal” condition. Metastatic disease for example, in itself may not be an indicator of futility from cardiopulmonary resuscitation (CPR) attempts, more the nature of the arrest and the general condition of the patient beforehand (2). In a study of 75 in-patients in a hospice two patients preferred not to know any details of their condition and just over one quarter preferred only limited information (3). Similarly, experience suggests, that even patients with an open understanding of their situation may not want details regarding death and the process and timing of it. These wishes need to be respected as far as possible (4). Sadly, too often, the discussion of CPR becomes a form filling exercise causing at times a great deal of harm and misses the opportunity for a more useful discussion of important issues. More reasonable guidance has subsequently been produced (5). Open and frank discussion matched to the patient’s wishes about all aspects of their condition is the practice we need to aim for. Having discussed that there are no more active lines of curative treatment and to start the preparation for the last phases of life it seems unnecessary and uncaring to then specifically discuss CPR. With an open awareness about death there are many more important areas to discuss than treatments offering no benefit. Yours faithfully Dr Andrew Thorns
1. Manisty C, Waxman J. Higginson I. Doctors should not discuss resuscitation with terminally ill patients. BMJ 2003;327:614-16 2. Ewer MS, Kish SK, Martin CG, Price KJ, Feeley TW. Characteristics of cardiac arrest in cancer patients as a predictor of survival after CPR. Cancer 2001; 92:1905-12 3. Murtagh F, Thorns A. Evaluation of an ethics history with hospice in- patients to improve information-giving and decision-making. Poster. European Association of Palliative Care Congress, The Hague. April 2003. 4. Boyd K. Deciding about resuscitation. Journal of Medical Ethics 2001; 27:291-294 5. NCHSPCS and APM. Ethical decision-making in palliative care: cardiopulmonary resuscitation (CPR) for people who are terminally ill. NCHSPCS London Jan 2002 Competing interests: None declared |
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W. Matthew Widdowson, Radiation and Medical Oncology St Lukes Hospital, Rathgar Dublin 6, Eire, KJ Madhavan
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The debate on resuscitation of terminally ill patients makes interesting reading and highlights the difficulty and dangers of trying to formulate a single policy for all. Higginson (1) makes an extrapolation that is fundamentally flawed; that all patients would want to be involved in decisions with regard to resuscitation just as they desire to participate in decisions at all other levels of diagnosis and treatment. Cardiopulmonary resuscitation (CPR) is the mother of all interventions; discussing CPR may often convey to the patient a sense of imminent death that the underlying condition does not necessarily imply. While the charge of paternalism is easily placed against doctors, to assume patients would want to discuss an issue as upsetting as CPR is in effect passing the burden of decision making to patients and their families. While this is desirable to some, others would see it as onerous and inappropriate. Manisty and Waxman (2) have made a robust argument, principally on the grounds of medical futility. They have rightly placed resuscitation as a unique and ineffective end of life intervention. We cannot help agreeing that encouraging patient choice when it effectively does not exist is tokenism, but again suggest caution in approaching the issue from one side alone. The difficulty in this arises from the very nature of terminal illness; it is poorly defined (3) and difficult to predict. The joint guidelines make no attempt to do so either. Variability in clinical situations needs to be recognised and accounted for. The authors of both articles will be aware of differing attitudes of cultural groups to end of life decisions. Our own joint experience of working within different health systems and with diverse racial, religious and ethnic groups would suggest caution in having a diktat for all people at all times. 1.Higginson IJ. BMJ 2003; 327: 615-616. 2.Manisty.C,Waxman.J. BMJ 2003; 327: 614-615. 3.Modern Oncology.An A-Z of key topics.Alatair Munro GMM .2001 Competing interests: None declared |
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Phillip J. Colquitt, Writer Working from my PC.
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Being hirsute in the chest area may protect one against an unwanted resuscitation. Semi Automatic External Defibrillators[SAEDs] are now common in Australian hospitals. Unfortunately, the ordinary disposable razors often accompanying the SAED probably won't remove hair from a male with carpet chest, The self-adhesive paddles of the SAED need a clean dry skin to be attached properly. A delay in the all important analysis and shock, and so a less than satisfactory resuscitation, or a perhaps a highly satisfactory end for those not wanting CPR. Competing interests: None declared |
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Madhumita Bhattacharyya, Specialist Registrar Department of Medical Oncology, St BArtholomew's Hospital, London EC1M 7BE, Chris J Gallagher
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To the Editor, The recent debate into the discussion of resuscitation in terminally ill patients raises important questions 1. Cardio-pulmonary resuscitation is an emotive issue and gaining the informed consent of patients for do- not-resuscitate (DNR) orders is often difficult. We cannot avoid the issue of DNR orders as this just leads to the least empowered junior staff and nurses having to face anguished demands at the time of death unless its inevitability has been accepted by the patient and family. We conducted a survey of views on resuscitation in 37 outpatients with cancer. 86% of these patients wished to be asked in advance whether or not they should be resuscitated, however, their understanding of resuscitation was limited. Although the questionnaire stated clearly an overall success rate of resuscitation in cancer patients of 5%, the overall perceived success rate was high. The median estimated success rate was 70% in those previously well (range 0-100%) and 50% in patients with cancer (range 0-80%). Resuscitation was associated with mouth-to-mouth breathing (84%) and “thumping of the chest” (89%) and less with electric shocks (77%) and ventilation (69%). Agreeing to a DNR order is more difficult for those patients who are not actively dying from their cancer yet who have a relatively short expected life span in terms of weeks to months. 46% of our surveyed patients felt that CPR should be always attempted in this prognostic group and 27% felt that it should never be attempted. If the prognosis was hours to days, 50% of patients felt that resuscitation should be never attempted and 50% were unsure. Providing informed consent to patients is fraught with difficulty as patients have pre-conceptions and fears of the implication of a DNR decision. We produced a patient information sheet on Cardiopulmonary Resuscitation, which was circulated amongst members of staff and to patient advice agencies but were unable to reach agreement on the level of information that should be provided without causing distress to the patients. As doctors, we are expected to discuss resuscitation with patients, but patient perceptions of its role and success often differ from our own. In practice, gaining informed consent remains a challenge in this setting and cannot be achieved without raising public awareness of resuscitation. Yours faithfully, Madhumita Bhattacharyya
Chris J Gallagher
Dept of Medical Oncology, St Bartholomew’s Hospital, London, EC1M 7BE 1. Waxman J, Higginson IJ. For and against: Doctors should not discuss resuscitation with terminally ill patients. BMJ 2003;327:614-616. Competing interests: None declared |
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