Intended for healthcare professionals

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
  1. Margaret McCartney, general practitioner, Glasgow
  1. margaret{at}margaretmccartney.com

When US doctors were asked if they would want cardiopulmonary resuscitation (CPR) in the case of major cerebral injury, 90% of them said no thank you.1 CPR, as with all treatments, has limitations and side effects, causing bodily injury and, in terminal illness, a medicalised death. It changes our last minutes from what could be a peaceful process into a medical battleground. And it’s been found to be “futile” in patients receiving palliative care for cancer.2

So it’s a concern that the Court of Appeal has found that doctors breached a British patient’s right to a private life when they added a “Do not attempt cardiopulmonary resuscitation” (DNACPR) order to her notes without her knowledge.3 4

Janet Tracey had terminal lung cancer, a “serious” cervical fracture after a road crash, and chronic respiratory problems, and was not improving. There was a discussion and the first, contested, DNACPR order given. A few days later Tracey’s daughter looked up DNACPR on the internet, was “horrified,” and asked that the order be removed.

Tracey’s condition deteriorated but, despite efforts, she “did not wish to discuss the issue.” Her husband thought that she had felt “badgered” by doctors to discuss end of life treatment. A second DNACPR order was discussed with her family and written in her notes. She died shortly after.

The judgment states that CPR is “potentially life saving” and that therefore “there should be a presumption in favour of patient involvement” in a DNACPR decision. Indeed, but does every decision not to offer ineffective treatment—organ transplant, chemotherapy, dialysis—need to become “patient informed” to absolve doctors from potential future blame? Should “badgering” be the norm?

How informed must patients be? The judgment says that the words “slip away” were inadequate because they were not “fully understood.” I too have used such words for the likely form of death without CPR. Should we now ensure that every patient whom we think is near death—and their relatives—understands in gritty detail that they will not be offered CPR even though it would be useless? Is this kind?

The judgment says that it would only be “inappropriate to involve the patient . . . if the clinician considers that to do so is likely to cause her to suffer physical or psychological harm.” Communication is all; the default should be sharing all information.

In the real world, however, patients present semiconscious and with recent terminal diagnoses; families disagree; and imparting and checking the understanding of information may require days when there are only hours left. Doctors are human, and we seldom have just one patient requiring our attention.

Meantime, CPR is becoming fetishised. Doctors withholding it will have to explain themselves. But doctors who break ribs and bruise the lips of terminally ill people, even knowing its futility, will not. Can this really be what patients want?

Notes

Cite this as: BMJ 2014;348:g4180

Footnotes

  • Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: I’m an NHS GP partner, with income partly dependent on QOF points. I’m a part time undergraduate tutor at the University of Glasgow. I’ve authored a book and earned from broadcast and written freelance journalism. I’m unpaid patron of Healthwatch. I make a monthly donation to Keep Our NHS Public. I’m a member of MedAct. I’m occasionally paid for time, travel, and accommodation to give talks or have locum fees paid to allow me to give talks but never for any drug or public relations company. I was elected to the national council of the Royal College of General Practitioners in 2013.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Follow Margaret McCartney on Twitter, @mgtmccartney

References

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