Bioethics

Prairie Messenger May, 2000 Mark Miller, C.Ss.R., Ph.D. One of the most disconcerting experiences for many people who come into hospital today is the question, “if your heart stops, would you want us to perform cardiopulmonary resuscitation (or CPR)?” The question is not asked of every person on every admission. But it is asked of the elderly, or those undergoing serious operations, or those whose general condition is rather poor. The question is asked because in a hospital there are people trained to attempt to restart a heart that has quit beating. And the question is disconcerting because most of us assume that the doctor ought to make that decision! However, there are two things to understand about CPR. First, what is seen on the television program ER does not reflect the realities of providing patients with CPR. On ER, a reasonably healthy patient goes into cardiac arrest (hospital talk for “the heart stops beating”); CPR (or the use of electric paddles from a defibrillator) is performed and the patient returns to his/her state before the heart stopped. When I talk with nurses, a very different view surfaces of what usually happens with CPR. An older or very, very sick person’s heart stops; the team intervenes with pounding on the chest in a desperate attempt to restart the heart. Sometimes the team can hear bones breaking; sometimes the chest is crushed. Often (most of the time) the heart never does restart. Occasionally, the heart is started again only to discover that the lack of oxygen to the brain during the “down” time has caused moderate to severe damage. Sometimes the patient’s heart restarts, but the patient never regains consciousness, living on in a persistent vegetative state. Second, there are statistical studies of the effectiveness of CPR. These studies suggest that the success rate for restoring a heart to proper functioning may be as high as 40 per cent – in an operating room where everybody is prepared for this eventuality. The overall rate for successful CPR in a hospital, where the equipment and trained personnel is readily available, is sometimes as high as 20 per cent. Success will be determined, to a great extent, however, by the condition of the patient. One study showed that the success rate of CPR for the “frail elderly” was less than one per cent, with no comment about condition of the few patients who were resuscitated. (That is why most long-term care facilities across Saskatchewan will not do CPR on their residents unless specifically requested by the resident or resident’s family). So, why would a doctor scare you with the question, “Would you want CPR….. ?” The answer is simply because doctors cannot impose their values on you and your care. The doctor does not know whether CPR would be appropriate for you. You may look old and frail, but you have a lot of life to live – you want CPR even if it would only give you a 10 per cent chance of continuing to live! Another person (many nurses choose this after witnessing CPR) might say, no thanks; when my heart stops, God is calling me home. So you have to know what you would want under the circumstances of your particular condition. If you do not say anything (or if the doctor does not think to ask), you will receive CPR automatically if your heart stops because the assumption in a hospital is the staff is there to save lives (unless you have already been “declared palliative” – which means, “you have accepted the reality that you are dying”). What does the church say about this? Very simply, the church asks you to weigh the burdens and benefits of CPR in your situation. If the benefits even if risky, are strong, then you may refuse CPR, just like you may refuse any other medical treatment that is too burdensome under the circumstances. And how would you make that judgement? It depends on the circumstances. If I am old and very frail, knowing the statistics on CPR would suggest that it is pretty much a useless treatment, so why burden the doctors and nurses with it? If I have many complicating factors (congestive heart failure, diabetes, cholesterol-clogged veins), again I may see the effort of CPR as providing little or no hope. Just because we have medical treatment does not mean that we always have to use it. That hospitals assume they must use CPR on everybody who does not say no (and this is done both for legal reasons and to respect the right of patients to a treatment unless the patient gives an informed choice against it) is part of the hospital culture of saving lives. That it does not work very well means doctors need to discuss this option with patients who can then make their own choices. Nonetheless, the possibility of CPR can often come as an awkward question because it sounds like something will happen to one’s heart. If you are asked, think of the question as a preparation for a possibility. It may not be easy to choose what you want, but it is quite unfair to leave the decision to the doctor. Patients have asked for a say in their care. This has moved us away from the patriarchal system where the “doctor knows best”. However, with choices comes responsibility. What should I do? Remember two things when making such choices. First, you can ask the doctor and other medical personnel all the questions you can think of. Their primary job is to give you the best information so you can make the best choices for yourself. And, second, realize that modern medicine, despite the power we like to invest in it, can only do what is possible. Not all hearts can be restarted; people do die (and do have a right to die without being “tormented” by invasive measure of modern technology); and sometimes we do have a clear choice. Normally the doctor can give you time to think (which is a good time to think of any other questions), and you may have to talk with your spouse and family. However, it is your choice. One last point: it is also not uncommon for doctors today to ask this question of the immediate family of those who cannot make their own decisions due to dementia or unconsciousness. Again, you are responsible to make the decision for a loved one – but the decision should be based first and foremost on what you know of your loved one’s previously expressed wishes. Can you think of somebody in your family – a parent or grandparent, brother or sister, aunt or uncle – for whom you might one day have to make such decisions? Do you know what they would choose? Perhaps it is time to begin discussing such possible treatment decisions before there is a crisis and the doctor stands before you with the question, “What treatment is acceptable for you/your loved one?”