"Slow and Show" CPR: Patient's Best Interest?
Cardio-pulmonary resuscitation (CPR) is the term used to
describe the action of attempting to prevent a patient from dying from sudden
stopping of heart beat or breathing. CPR
has been an accepted medical technique for decades and has been performed both
on the outside and inside a hospital.
Within the hospital, it has been the policy over the years to provide
CPR to all patients suffering cardiac or pulmonary arrest with few exceptions
unless the patient has previously requested "do not resuscitate" (DNR)
and this request placed as a physician's order in the patient's chart.
Since, the time available for resuscitation to begin and have
any chance of being effective and prevent death is only a matter of a few
minutes at the most, CPR activity must begin promptly with a planned
resuscitation protocol including the identification of a cardiac and/or
pulmonary arrest event, arrival of medical personnel with necessary equipment
and the prompt initiation of resuscitation actions by the staff with
appropriate modifications depending on the patient's response. Though not all resuscitation attempts are
successful either to save the patient from death at the time, prevent
persisting damage from the event or permit a live discharge from the hospital,
without prompt and proper management, death will be the result.
Since CPR has been granted as default to all patients except
those who have requested DNR there will be patients who arrest and thus a
candidate for CPR who have terminal illnesses with no chance of a valued
recovery even if death at this point is prevented. But the question is "whose value?"
Should it be the determination of the
medical staff or should it be that of the patient? And when there is no DNR requested by the
patient either because the patient wanted CPR or that the patient was not
offered that alternative, should the medical staff be as energetic in
initiating and performing CPR in a patient who the staff assesses as already
terminal with unlikely long term benefit from that resuscitation attempt?
Over the years of CPR, there has been a practice which has
occurred in hospitals in which the medical staff having made their own prognosis
of a futile life if the patient survives and may decide to not arrive as
promptly as necessary to the stricken patient's bedside and when finally
starting a CPR activity fail to perform it in an energetic fashion necessary
for attempted benefit. These responses
have been titled "slow code" or even "show code" (only
"showing" that something was being done but not really doing it with
the goal of success.) This practice has
not been institutionally or professionally accepted over the years but is most
likely still being carried out.
Why? It is because since CPR is
the default action in hospitals for all patients except those with a DNR order,
there will be a number of patients who carry a poor overall prognosis and there
will be physicians and nursing staff who recognize this and find it difficult to be more energetic toward
these patients in response to an arrest.
The ethical issue is whether this response by the professionals is
really in the overall best interest of their patient or whether the patient
should have had an opportunity to make their own informed decision in advance
and that decision fully, completely followed by the staff irrespective of the
professional prognosis.
The other, alternative approach to encourage patient
decision-making would be to completely reverse the hospital policy: all
patients and families would be notified on admission that CPR is no longer
offered as a treatment unless specifically requested by the patient. There will
be no DNR request needed. After all, CPR was originally begun as a treatment
only for those in good health but with a sudden unexpected loss of heart beat
or respiration through an accident such as electric shock or drowning.
What do you think about the CPR-DNR issue for hospitalized
patients and about any persistent practice of "slow" or
"show" codes? ..Maurice.
posted by Maurice Bernstein, M.D. @ 11:28:00 AM
6 comments
6 Comments:
Not sure where you are coming from. All patients on admission should be asked for a code status. Very few families refuse a doctor's recommendation when it is asked properly. But it should be done by a physician familiar with the patient for optimal results. Having a resident or hospitalist ask a family they don't know if they want mom or dad coded may precipitate medically indefensible results. This becomes a greater risk in this era of few family physicians or internists taking care of their own patients in the hospital.
If the situation is hopeless and the family can't agree on DNR, I believe a brief attempt at CPR is warranted.
Ah, Joel you brought out the very argument that this thread is about when you wrote:
"If the situation is hopeless and the family can't agree on DNR, I believe a brief attempt at CPR is warranted."
I have no trouble accepting a relatively brief promptly started and energetically carried out resuscitation action if the "brief" duration is purely based on the patient's observed clinical response to the attempt. What I am concerned about is to initiate a "brief attempt" but based mainly on the pre-arrest "clinical situation" or the fact that the patient or family has not accepted a DNR. Otherwise such a "brief attempt" at CPR simply becomes, to me, an unacceptable "slow or show" code. ..Maurice.
I think a 'slow code' is absolutely reprehensible. Patients and their families are specifically given the right to choose. Medical personnel overriding that, sneakily and dishonestly, by basically pretending to code them are playing god, and taking away people's rights.
There are plenty of times, I'm sure, where a code is not a good choice. However, people make all sorts of bad choices in life - as we're a free country, they have the right to do that. No one, including medical personnel who think they're smarter than the patient, has the right to take those choices away.
TAM
What do my visitors think about this?:
Since virtually all major life-saving medical or surgical procedures carried out in the in-patient hospital setting requires the informed consent of the patient or patient's surrogate, why shouldn't permission to perform CPR as necessary be authorized in this manner at the time of hospital admission? The consent can be rejected at any time by the patient. By this approach to CPR, there would be no ambiguity with regard to the intent by the patient or the duties of the staff for attempt at effective resuscitation.
In a way, this approach, one could say, would make more sense since the vast majority of patients have no need for CPR during their stay and so this procedure should be one for patient acceptance rather than one for patient rejection as it is currently. Would it be unethical to reverse the current CPR practice of instituting a major procedure to be carried out on all patients based on hospital policy or the independent final decisions of the hospital staff and without the specific consent of the patient? ..Maurice.
Hospital policy should never override a patient's right to make decisions.
Something I call a living directive comes with me to the hospital. It's a combination of advance directives integrated with what I will and won't accept as treatment.
While I think anything to promote free will of the patient is a good thing, I can tell you that recently, at a major hospital, I witnessed a hospital staff gaining informed consent from a family member who had no right to do so AFTER the patient refused treatment.
While the outcome was ideal and the patient recovered and had no memory of the refusal (brain hemmorage), it bothered me how her free will was trampled.
While recovering she asked me to be her Power of Attorney and I explained that my job was to exercise her rights without regard to how I felt and had I been her POA during that time I would have let her die per her wishes.
This patient and I were very close and I knew how she felt about intervention after a stroke. So...at the age of 80 she had two brain surgeries and aside from a balance issue, was completely cured of her injury that happened due to a fall.
I have wondered since that time, what is the best thing when we don't know the outcome? Do we want CPR when we've had a severe stroke to live handicapped? Or, do we want to let it all go instead of living with a life altering disability? Tough call for the medical community and the patient. However, free will should always prevail.
belinda
Belinda, in all patient-made decisions at the time when informed consent is being offered, it is up to the attending physician to determine the patient's mental capacity to make that specific medical decision. That means, does the patient remember and understand what is being offered and the alternatives by responding to the physician's questioning? Can the patient explain the basis for his or her final decision? With regard to the latter, the decision need not be what the doctor may have decided but only whether the patient can reasonably explain the decision. Meeting these criteria demonstrates capacity irrespective of any other deficiencies in legal competence. If the patient is found not to have the capacity to make the medical decision then the individual who has the POA for healthcare can make the decision but based on what the patient had informed that person about desires in the past. This is called "substituted judgment". If there is no POA for healthcare for the patient, the physician must make a "best interest" decision based on communication with other individuals who have had contact with the patient in the past and/or what the "average person" might desire. When the patient has no capacity and there is no POA for healthcare but there is a written advance directive by the patient, the requests within the advance directive is to be followed though the physician must consider how the requests, as written, apply to the current clinical situation. For example, if it is written "under no circumstances should CPR be administered" there would be no ambiguity regarding the patient's desires under any clinical circumstance where as simply "no CPR" would raise the question as to whether the patient had considered situations in which CPR may have been fully successful and the patient would be left with a personal "worthy" and "wanted" life thereafter. An Advance Directive in which there is a brief detailing of requests makes the directive less ambiguous than simply checking off a box. ..Maurice.
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