I feel a pulse, but it’s weak,” says the young doctor who has just given prolonged cardiopulmonary resuscitation (CPR) to a patient, alongside a plethora of aesthetically pleasing co-saviours in scrubs. Cardiac monitors show one trace after another, the accompanying “beep-beep” acts as a rhythmic, universally recognizable soundtrack. Medical reality has been assimilated, altered, homogenized and sexed-up, in an attempt to create compelling hospital fiction. In real life, CPR is not as successful or straightforward.
As a palliative care consultant working in NHS hospitals, I have seen a great number of deaths that involved CPR. CPR can be a traumatic experience, not just for the recipient, but also for their loved ones and the healthcare professionals administering it. In the unlikely event of a palliative patient actually surviving CPR, they typically will not regain consciousness and if they do, they are in severe pain from the impact of the procedure on their body.
CPR should not be used as a synonym for its more widely used umbrella term “resuscitation”, which can mean giving someone who is severely dehydrated a few bags of intravenous fluid via a drip to make them better. Or, if someone is anaemic and has lost blood, a blood transfusion constitutes a form of resuscitation. None of this is CPR, which sits at the most extreme end of the resuscitative treatment scale.
CPR can be life-saving for those for whom there is a reasonable chance of success – I have administered it, and it has worked. CPR does not work well, however, for those who have severe, underlying morbidities and palliative conditions such as advanced cancer, heart disease and neurological afflictions. The number of CPR recipients that actually leave hospital alive is very small. For patients with cancer that has spread to other parts of the body, the average percentage surviving CPR and then leaving hospital in a study was 1.9%. The average number for patients over the age of 80 in the same study was around 3%.
Ask any doctor and they will tell you of CPR scenarios they have witnessed when the procedure seemed entirely wrong, futile, even undignified. CPR is a hard, ferocious, bone-breaking clinical intervention, and too often prolongs the death and dying event.
Modern medicine, however, still shies away from discussions about natural death and dying, and is more comfortable in the realms of what can be done. Doing something always trumps doing nothing. Healthcare professionals have become willing interventionists, and we cannot stop meddling, interfering and attempting to fix.
Many people I speak to presume that if the label “Not for CPR” or “DNACPR” (Do Not Attempt CPR) is added to their notes, this might preclude them from other resuscitative treatments such as antibiotics, fluids and blood transfusions. Dispelling this myth takes time and reassurance. Patients can still have active, resuscitative measures if they become increasingly unwell, but remain not for CPR for when their heart stops.
Experienced healthcare professionals find it hard to broach the topic of dying. They fear that talking about it may imply they are giving up on the patient, and/or they are not mentioning a bad prognosis and are instead talking about DNACPR forms. Neither is true.
Avoiding the discussion becomes a strategy for some medical professionals, in particular those who have had bad experiences communicating DNACPR. Healthcare professionals are human beings who find these discussions hard, and sometimes go about them nervously and clumsily. The pressure to have such discussions was increased in 2014: a landmark ruling by the Court of Appeal, meant that doctors now have a legal duty to inform patients if they want to place a DNACPR order on medical notes.
We are perhaps all at risk of receiving this forceful physical intervention in our dying moments purely by default in an ever more depersonalized, shift-working medical world, unless we explicitly make our views known. This situation can be avoided if it is talked about openly among patients, family and healthcare professionals, ideally well in advance, and a DNACPR form is filled in and added to the patient’s notes. In this age of patient empowerment, choice and shared decision-making, healthcare professionals will have to talk frequently about this “opt-out” at the end of life.
Hopefully, in an increasingly healthcare-savvy and informed society, patients themselves can start these discussions. Here in Wales, the All Wales DNACPR policy aims to be one of the most transparent and patient-centred in the world. The discussions, documents, policies and shared decision support videos surrounding this Wales-wide approach came about through a willingness by clinicians, policymakers and patient groups to create a unified approach.
The Welsh NHS’s DNACPR approach, called Sharing and involving, is based on the premise of allowing a natural and anticipated death in frail patients. The aim is to get everyone to debate and actively discuss DNACPR. Having one approach across all settings in Wales means potentially easier communication with and between hospitals, hospices, the community and other settings when people move from one place to another. It also empowers patients and family members to be clear with any healthcare professional they meet about what treatments they would consider, and which they would not.
It will not change the glorified portrayals of CPR in written and audiovisual fiction, but it should help make a big difference to the dying moments of many, and make that precious time a little more dignified.
Source: The Nation Newspaper