Views & Reviews No Holds Barred

Is discussing futile treatments really best for dying patients?

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g4180 (Published 24 June 2014) Cite this as: BMJ 2014;348:g4180

CPR can be futile – and is sometimes worse

Dr McCartney raises important points about the futility of CPR in some dying patients(1). In the Judgement she refers to, the Lord Justices chose to emphasise that there was some possibility of success following CPR – repeatedly referring to its potentially life-saving nature(2).

While CPR is, of course, a valuable intervention in many patients, a 2013 systematic literature review provides good evidence that “given terminated tumour-directed treatment, extensive metastasis and a performance status poorer than WHO 2, [there is] a basis for maintaining that cardiopulmonary resuscitation will be unsuccessful. A PAM index of > 8 in a palliative care cancer patient points in the same direction”(3). This is surely important information not only for a patient choosing how to pass the closing days and moments of their life, but also for doctors caring for those patients.

As both Dr McCartney and the Lord Justices discuss, sensitive communication with patients and their families is extremely important. One difficulty with this may be a lack of basic knowledge about the reality of CPR(4). TV portrayals of CPR commonly focus on young people with trauma-related cardiac arrest and, “contrary to reality”, show no age-related difference in likely success rates(5). Older patients only rarely seek out more detailed information(6). The Judgement suggests that the issue of DNACPR affects more than half of the population so it, and the associated media coverage, feel like wasted opportunities to share important information about CPR and the constraints on its success. I would contend that the calculation offered is actually an underestimate: it ignores the increasing number of people who die at home, and also forgets that those people who are successfully resuscitated, for example from an MI, will inevitably age and die of something else.

As an out of hours GP not infrequently asked to confirm death in patients who have received CPR, I would also like to suggest that, some of the time, full resuscitations seem worse than futile. It’s not good to see frail, elderly, palliative care patients on the floor, with their clothing in disarray, and an intubation tube still protruding from their mouth. Family members are understandably distressed not only by what happened during the death itself, but also afterwards, when it’s difficult to say goodbye to a medicalised corpse.

(1) BMJ 2014;348:g4180
(2) Court of appeal (civil division) on appeal from the High Court of Justice, Queen’s Bench division administrative court Mrs Justice Nicola Davies DBE [2012] EWHC 3860 (Admin). Case No: C1/2013/0045. http://www.judiciary.gov.uk/wp-content/uploads/2014/06/tracey-approved.pdf
(3) Cardiopulmonary resuscitation in palliative care cancer patients. Review article. O J Kjørstad, D F Haugen. Tidsskr Nor Legeforen 2013; 133:417 – 21. English translation at: http://tidsskriftet.no/article/2977206/en_GB
(4) Development, validation, and results of a survey to measure understanding of cardiopulmonary resuscitation choices among ICU patients and their surrogate decision makers. ME Wilson et al. BMC Anesthesiol 2014;14(1):15.
(5) Resuscitation on television: realistic or ridiculous? A quantitative observational analysis of the portrayal of cardiopulmonary resuscitation in television medical drama. D Harris, H Willoughby. Resuscitation 2009;80(11):1275-9.
(6) Communicating information on cardiopulmonary resuscitation to hospitalised patients. R Sivakumar et al. J Med Ethics 2004; 30:311-2

Competing interests: When my dad died from metastatic cancer, no-one attempted CPR. Instead, I kissed him, told him I loved him and laid down beside him.

01 July 2014
Caroline Mawer
GP
Tower Hamlets, London