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An Indecent Proposal: Withholding Cardiopulmonary Resuscitation

Corresponding author: Barbara J. Daly, RN, PhD, FAAN, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106-4904 (e-mail: barbara.daly{at}case.edu).

In the February 20, 2008, issue of the Journal of the American Medical Association, Peberdy and associates¹ reported an analysis of probabilities of survival from in-hospital cardiac arrest. Although their purpose was to examine whether outcomes differed according to the time and day of the week when the arrest occurred, their data raise other important questions about use of cardiopulmonary resuscitation (CPR). The current norm in acute care facilities is to assume that CPR should be performed in every case of cardiac arrest, unless a specific physician order to the contrary is in place. In this column, I propose a reversal of this; that is, I propose that in every case of cardiac arrest, unless a specific physician order to the contrary is in place, CPR should be withheld.

The Argument

This proposal rests on well-established principles of bioethics, professional norms, and data about the effectiveness of in-hospital CPR. To begin our discussion of what some may consider an "indecent proposal," we should ask about the justification for any intervention. Modern health care offers an amazing array of helpful interventions, but most come with burdens, side effects, and sometimes considerable pain and suffering. What justifies imposing this harm on our patients?

Foundational to ethical practice are 2 requirements: informed consent and the fiduciary duty to act in the patient’s best interest.^2,3 We may not impose interventions on patients, regardless of intention to help and regardless of good evidence about the likely effectiveness of the proposed intervention, without the patient’s well-informed permission. This requirement entails the obligation to inform patients of the likely benefits and burdens of the proposed intervention as well as alternatives.

In addition to consent, we also must have a reasonable expectation that the intervention will promote the patient’s good. Such an expectation requires both a probabilistic judgment of the likelihood that the intervention will produce the intended physiological effect and a judgment that the physiological effect will, in fact, be evaluated by the patient as a desirable state, worth the likely burdens and costs of the intervention.

Consider how the default practice of CPR holds up against these criteria. Although the Patient Self-Directive Act of 1990⁴ requires that patients be asked about the presence of advance directives on admission, they are not routinely asked about their preferences or views about CPR. In addition, patients are rarely given the facts about success rates, and thus the first requirement, for informed consent, is often violated.

Fifteen years ago, Schneider et al⁵ reported on a review of 98 reports of in-hospital CPR during the period from 1960 to 1990. Their analysis revealed an overall 15% rate of survival to discharge among the 19 955 occurrences of CPR. The more recent report from Peberdy and colleagues¹ used data from the National Registry of Cardiopulmonary Resuscitation, a multisite registry of in-hospital resuscitation events. The registry documented an overall survival rate of 18.1% among the 86 748 cardiac arrests that occurred between 2000 and 2007, with 13.9% "favorable neurological outcomes." Survival rates in high-risk groups, such as patients with renal failure and advanced cancer, are even lower.^6,7 In contrast to this factual data, a survey of the public reported that, on average, respondents estimated that 65% of patients undergoing CPR would be successfully resuscitated.⁸

"These data suggest that not only is the public inadequately informed about the effectiveness of CPR, but that in general CPR is associated with poor outcomes. "

 

In the 2005 American Heart Association (AHA) Guidelines for CPR and Emergency Cardiovascular Care, the AHA adopted the phrase "Do Not Attempt Resuscitation," replacing the former "Do Not Resuscitate."⁹ This change reflects an important shift in how we think about what we do, and it represents more than semantic accuracy. Using chest compression, defibrillation, and the other elements of Advanced Cardiac Life Support most often does not resuscitate the patient—it is an attempt to resuscitate. Thus the decision to withhold CPR does not constitute a decision to allow someone to die who would otherwise live; rather it represents a decision to withhold an intervention that is most likely to be ineffective.

These data suggest that not only is the public inadequately informed about the effectiveness of CPR, but that in general CPR is associated with poor outcomes. Widespread, indiscriminate use of CPR thus also fails the second criterion of justification: a reasonable expectation that the intervention will promote the patient’s good.

The Proposal

The objective of my proposal is to restrict use of CPR to those patients who provide adequately informed consent and for whom CPR has a reasonable chance of success (ie, discharge from the hospital without significant impairment in cognitive status). Although this proposal entails a major change from standard operating procedures, it merely requires that the use of CPR be governed by the same principles as all other invasive procedures. If the proposed intervention is believed to meet the 2 foundational justifications for intervention, it should be specifically prescribed by a physician—the same requirement for every other high-risk, burdensome intervention.

This proposal is quite likely to meet with vigorous objection. These objections will probably take several forms, including the following assertions.

1. We can assume that most patients want CPR. This assertion can be defeated in a number of ways. First, the existence of living will statutes in almost every state certainly suggests that at least a sizable minority, if not a majority, of individuals have made specific decisions to limit life-sustaining interventions in some situations. Although the actual use of living wills is variable and the terms of living wills vary from state to state, the existence of this legal instrument does shed doubt on the assumption that the majority of acutely ill, hospitalized persons would elect to undergo CPR if adequately informed of probable outcomes.
   Second, studies specifically investigating chronically and acutely ill patients regarding their wishes for CPR have shown that a substantial number of people would not want resuscitative attempts if the probability of survival was low or their quality of life was poor. Frankl et al,¹⁰ for example, found that 90% of inpatients interviewed desired life support if their health could be restored, but only 30% desired life support if they would be left unable to care for themselves; only 6% desired it if they would be left in a vegetative state. In the well-known SUPPORT study,¹¹ 31% of patients, all of whom had a life-threatening diagnosis, preferred that CPR be withheld. Patrick and colleagues¹² interviewed 7 cohorts of patients with diverse health states about their treatment preferences in hypothetical future states. Coma was rated as worse than death by 52% of the 341 participants, and 85% would refuse CPR in this situation.
   
2. CPR won’t be ordered when it should, and thus lives will be needlessly lost. Worry about inadvertent omission of orders to use CPR in case of arrest is an important concern to address. Fortunately, with the growing use of electronic medical records, this risk can be minimized relatively easily. Electronic systems can be programmed with automatic prompts if no order for CPR has been made, alerting the physician to the need to order CPR if it is thought to be appropriate. It is also possible to use mandatory fields on admission screens that must be completed before further orders can be entered. The field can be set up indicating the default "DNAR" (Do Not Attempt Resusitation) status and requiring the physician to either confirm this or order CPR in case of arrest. The Figure is an illustration of a such a screen that could be used with hospital admission orders.
   
3. Medical progress will be slowed with the decreasing use and evaluation of specific aspects of CPR. Although we certainly have learned from our experiences and continue to learn from data provided through the CPR registry, we are unlikely to learn anything of value from the continued inappropriate use of CPR. The intention of this proposal is not to stop the use of CPR; it is to ensure that indications for use and for withholding CPR are thoughtfully evaluated and to promote sensitive discussions with patients and their families about the plan of care.
   
4. Instituting DNAR as the default status would promote the practice of passively allowing DNAR orders without talking to the patient or the patient’s family. The current expectation is that physicians and nurses have ongoing discussions with patients and families about treatment decisions. However, no formal requirements or order system features prohibit medical orders from being written without appropriate discussions. In fact, persistent discomfort with the topic and reluctance on the part of clinicians to raise the issue of treatment limitations, as well as inadequate education in how to hold these discussions, is considered by some a major contributor to the overuse of CPR.¹³ The proposed change to a default status of DNAR is unlikely to either improve or reduce the likelihood of thoughtful discussion with patients and their families, but there is no reason to think it would add to the discomfort with addressing the topic.
   
5. There is no disadvantage to performing CPR, even if the patient does not survive. Because we cannot predict with certainty who might benefit, we should err on the side of using CPR in most cases. This argument contains both a flaw in its premise and a misunderstanding of what is proposed. First, it is simply not accurate to claim that futile CPR has no disadvantage. Indiscriminate use of CPR has 2 important and serious negative consequences. As noted in the reviews of CPR use, a substantial portion of survivors are left with neurological damage. Using the data reported by Peberdy et al¹ on CPR attempts reported to the registry, 3628 patients were left with "unfavorable neurologic outcomes." Given that the registry data are from roughly 10% of acute care hospitals in the United States, we can estimate that more than 30 000 patients were left with cognitive impairment after CPR in the 7-year reporting period.
   

View larger version (45K): [in this window] [in a new window]   Figure Sample of electronic record screen for mandated determination of resuscitation status. Abbreviations: CPR, cardiopulmonary resuscitation; DNAR, do not attempt resuscitation.

"The objective of my proposal is to restrict use of CPR to those patients who provide adequately informed consent and for whom CPR has a reasonable chance of success (ie, discharge from the hospital without significant impairment in cognitive status). "

 

Conclusion

Cardiopulmonary resuscitation and full use of the techniques of advanced cardiac life support have saved countless lives in the 50 years since Kouwen-hoven and colleagues¹⁵ first reported on the success of closed-chest compression. Widespread use of CPR in the early decades has enabled investigators and clinicians to continuously improve techniques and to learn much about the potential and the limitations of this rescue intervention. It is time, now, to apply what we have learned in order to minimize the harm that is associated with inappropriate use while we continue to offer this important and potentially life-saving procedure to those for whom it was originally intended.

Finally, it can be asked why this issue should be addressed by nurses. After all, it is physicians who have responsibility for issuing the DNAR order. Nevertheless, I believe that this issue should be championed by nurses for a number of reasons. It is most often nurses who are at the bedside with the patient when the arrest occurs, and nurses are likely to find themselves in the difficult position of having to initiate CPR in situations where it is either not appropriate or not desired. Nurses are system experts and have demonstrated the ability to initiate changes in the operational routines of critical care units on countless occasions. Nurses also are quite likely to be involved in the design of electronic medical record systems and thus may have the opportunity to ensure that mandatory resuscitation status screens are incorporated. And, as with other social changes, if not you, then who?

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FINANCIAL DISCLOSURES
None reported.

REFERENCES

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4. The Patient Self-determination Act of 1990, Sect 4206, 4751 of the Omnibus Reconciliation Act of 1990, Pub L No. 101-508 (November 5, 1990).
5. Schneider AP, Nelson DJ, Brown DD. In-hospital cardiopulmonary resuscitation: a 30-year review. J Am Board Fam Pract. 1993;6(2):91–101.[Medline]
6. Cohn EB, Lefevre F, Yarnold PR, Arron MJ, Martin GJ. Predicting survival from in-hospital CPR: meta-analysis and validation of a prediction model. J Gen Intern Med. 1993; 8:347–353.[Medline]
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This article has been cited by other articles:

				A. Nader and M. G. Seneff In-hospital CPR: Performing it Better but Less Often J Intensive Care Med, May 1, 2009; 24(3): 208 - 209. [PDF]

				B. J. Daly Response Am. J. Crit. Care., November 1, 2008; 17(6): 501 - 501. [Full Text] [PDF]

				T. M. Pope DNAR as Default Status: Desirable in Principle, Difficult in Practice Am. J. Crit. Care., November 1, 2008; 17(6): 500 - 501. [Full Text] [PDF]

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