Resuscitation

1. To care, to control, to comfort Resuscitation Dr Abbie Flinders Specialist Registrar – Care of the Elderly 2007

2. Introduction • Emotive subject • Own ideas, thoughts and expectations • Many opportunities for miscommunication • Ethical dilemmas • Needs a rational and guideline based approach

3. To begin discussing this topic we need to ensure all concerned understand • What CPR is • And…. • What it is not

4. CPR is… • External chest compressions • Artificial respiration • Defibrillation

5. CPR is not… • Investigation or treatment of reversible conditions • Analgesia • Antibiotics • Any drug for symptom control • Feeding or hydration • Suctioning • Seizure control • Treatment of choking

6. Why do we need to think about CPR or to make advanced decisions? Why has there been an increased focus on CPR decision making in recent years?

7. Medicine has changed • People survive acute illnesses they previously would not have. • Medical intervention is keeping people with chronic disease alive for longer. • People with cancer receive drugs not for cure but to increase quality and often length of life.

8. Basic medical ethical principles • To do good • To do no harm • Respect autonomy • Justice

9. To do good… • Our aim is to restore or maintain health. • Is CPR therefore beneficial as it prolongs life?

10. Doing harm… • Prolonging suffering? • For person receiving/surviving CPR • For families • Success rates of 15% shown in large studies • Diminishing quality of life? • At least 2/3 of out of hospital cardiac arrests have new neurological or functional problems

11. Respecting autonomy • Our role is to give information and guidance to help people make choices. • Need to identify people who would choose not to undergo CPR • Is CPR a viable option at all? • We cannot ask opinion on a treatment option that is not available

12. Justice… • Non-discriminance • Making the best of available resources

13. Human Rights Act Article 2 – the right to life Article 3 – to be free from inhuman or degrading treatment Article 8 – to respect privacy and family life Article 10 – to freedom of expression including the right to hold opinions and receive information Article 14 – to be free from discriminatory practices in respect of these rights

14. How we should go about making the decisions • Circumstances of cardiopulmonary arrest • Likely clinical outcome • Where death is expected due to underlying disease • All other circumstances Ultimately the final decision lies with the most senior medical person looking after the person – either consultant or GP.

15. Particular issues related to palliative care

16. The expanding role of palliative care • Palliative care used to be confined to terminal care • Increasing life expectancy for people with “incurable disease” • Integral part of community and hospital care (no longer confined to the hospice) • Need to distinguish who is receiving terminal care

17. CPR in the hospice • Previously “blanket” do not resuscitate policies • Change in case mix in hospices • Shift towards terminal care in community • Bed closures • Palliative care does not aim to prolong life but it certainly doesn’t aim to shorten it!

18. So is CPR ever appropriate in the context of palliative care?

19. Case of MWelsh hospice 2001 • 47 year old woman • Malignant melanoma excised from leg • 6 months later – chemotherapy for liver metastasis • Vertebral metastases leading to spinal cord compression • Radiotherapy • Hospice admission for neuropathic pain

20. Intrathecal opioid infusion arranged • During procedure • Apnoeic • Bradycardic – pulse 4 bpm • BP unrecordable • CPR commenced + atropine + adr • Transferred to acute hospital

21. Spontaneous circulation recovered after 5 mins • Spontaneous respiration after 50 mins • Transferred back to hospice 48hrs later • Died two weeks later • Had time to put affairs in order • She and family felt correct decision had been made

22. In the hospital • Increasing numbers of palliative and terminal care patients admitted to acute hospitals • Reluctance to make decisions • Night and weekend admissions with little information on long term condition

23. Mr X • Metastatic pancreatic cancer • Living at home with family support • Sent in by GP for exclusion of DVT • On arrival – 10pm due to ambulance delays • Hypotensive • Drowsy • Clinical DVT

24. Entering terminal phase • Is there anything reversible? • Had he been deteriorating in recent days/hrs • GP sent in for exclusion/treatment of DVT, what does this suggest? • CPR decision needed asap!

25. These types of situation are extremely stressful for the teams and families looking after the person and should be avoidable

26. A word on communication • 30% of doctors feel uncomfortable discussing CPR with patients (Stolman et al) • Yet this is one of the most important parts of the decision making process

27. What do patients and relatives think? • Morgan et al studied views of elderly patient and their relatives • Mean age was 80 • Most (98%) did not feel uncomfortable discussing their own CPR status and in fact welcomed it • 25 out of the 87 people who did not already have a not for CPR order in place, requested one

28. Advance directives & Living wills • Formal way to document wished regarding future treatment • No statutory legislation covering them, they are upheld by common law • Usually involve decisions re CPR, antibiotics, surgery, ITU care and ventilation

29. May not contain statements regarding: • Illegal acts such as euthanasia • Demanding treatment contrary to the clinical judgement of the medical team • Refusal of food or drink by mouth • Refusal of measures or treatment designed solely for comfort e.g. analgesia

30. Summary • Extremely complex and emotive subject • Increasingly important to encourage open discussions, transparent decision making • Ensure written and verbal information available to all • Ethical principles at the forefront of decision making to concentrate on providing CPR to the correct cohort of patients and ensuring a good death for as many people as possible

31. Thank you