CPR in old patients in hospital: is it futile?

1. CPR in old patients in hospital: is it futile? Dr Paul Diggory Consultant Physician, Elderly Care Medicine and Orthogeriatrics Mayday University Hospital, London

2. Cardiopulmonary Decisions Futile procedure ?

3. When should a DNAR order be considered? When patient’s condition is such that CPR will not be successful Where there is no benefit from restarting the heart (Will not benefit if no awareness of self or ability to interact) Where the benefit is outweighed by the burdens Decision relating to CPR. BMA, Resuscitation council & RCN October 2007. www.bma.org.uk/ethics

4. Cardiopulmonary Resuscitation Developed in the 1960 Used in highly selected patients Gradually expanded to other groups Trained Teams and equipment Kouwenhoven WB, Jude JR, Knickerbocker GG. “Closed-chest cardiac massage” (1960) 173 JAMA 1064

5. Effectiveness of CPR • Recognise arrest Rapidly • Adequate CPR team • Training in CPR • Equipment / drugs

6. Effectiveness of CPR(In Hospital Arrests) • Survival to leaving hospital 2 to 20% • Worse outside ‘High Dependency Areas’ • Worse if not Ventricular Fibrilation • Worse for older people • High risk of Brain damage (35% of CPR survivors over 80yr) • High risk of Rib #s, Splenic rupture “Survival after CPR in the hospital.” 1983; 309: 569. N Eng J Med 569 “Why outcome of CPR in general wards is poor.” 1982; i: 31 Lancet “Analysis from the brain resuscitation clinical trials. The Brain Resuscitation Clinical Trial I and II Study” (1995) 23 Crit Care Med18 “Cardiopulmonary Resuscitation of older people.” (1983) 2 Lancet 267

7. CPR Prognosis • Prognosis following CPR is Poor for those with: • Infection, LVF, Metastatic Carcinoma, Renal or other Organ Failure. Less than1% survive (Few of these leave hospital) BMJ. 1992; 304:1347-51.. N Eng J Med. 1983; 309:569-75. Am J Med. 1989; 87:28-34. Ann Int Med. 1989; 111:199-205. J Am Ger Soc. 1994; 42:137-41.

8. Prognostic ScoresTo predict those who will NOT survive CPR • Pre-Arrest Morbidity score • Prognosis After Resuscitation score • Modified Pre-Arrest Morbidity Index “Predicting unsuccessful CPR: a comparison of three morbidity scores.” Resuscitation 1999; 40: 89

9. Prognostic Scores Always Somebody who is an exception Scores do not always agree Scores do Not predict those patients who will survive “Predicting unsuccessful CPR: a comparison of three morbidity scores.” Resuscitation 1999; 40: 89 “The influence of new guidelines on cardiopulmonary resuscitation (CPR) decisions. Five cycles of audit of a clerking Proforma, which included a resuscitation decision” Resuscitation. 2003; 56: 159-165.

10. Important CPR IssuesWhy make a decision • Time spent on patients who will not survive

11. Important CPR IssuesWhy make a decision • Time spent on patients who will not survive • Each Quality adjusted Life Year is $240,000 * (NICE uses benchmark of £35,000 for new treatment) * KH Lee. Critical Care Med. 1996; 24: 2046-2052

12. Important CPR IssuesWhy make a decision • Time spent on patients who will not survive • Each Quality adjusted Life Year is $240,000 * (NICE uses benchmark of £35,000 for new treatment) • Prevents others from receiving care • (Simultaneous arrests & takes Crash team away from patients. • Doctors have a legal an ethical Duty to maximise resources.**) * KH Lee. Critical Care Med. 1996; 24: 2046-2052 ** R v Cambridge HA [1995] 6 Med LR 250, Re J. (A Minor) Wardship: Medical Treatment [1992] 4 ALL ER 614

13. Problems with CPR

14. Changes in Public Attitudes to CPR • Decisions about CPR example of Ageism • Age Concern • Press Reports • Medical Journal Articles * • Public Perception of CPR • Occurs in fit young people • Has 75% success rate** • There is a right to CPR * S. Ebrahim. BMJ. 2000; 320:1155-6 ** S Diem. NEJM. 1996; 334:1578-1582

15. CPR decisions Increasingly under scrutiny

16. CPR decisions Increasingly under scrutiny Legal Problems

17. CPR decisions Increasingly under scrutiny Legal Problems Ethical Problems

18. How might the Law apply to cardiopulmonary resuscitation decisions?

19. English Law • European Law • (Human Rights Act 1998) • Common Law • (Burke v GMC & Ors [2005] EWCA 1003) • Statute & Statutory Instruments • ( MCA & NHS Executive. Resuscitation Policy. ( HSC 2000/028 )) • Circulars & Guidelines • (BMJ/RCN/Resucitation Council guidelines)

20. European Law(Human Rights Act 1998) • Article 2. Right to life (Death penalty, self defense, just war) • Article 3. Not to be subjected to torture (Inhuman or degrading treatment) • Article 8.* Respect for private & family life (Confidentiality involvement of relatives) • Article 9.* Freedom of thought & Conscience (Treatment on basis of religion/moral beliefs) • Article 10.* Freedom or expression (Receive information/Confidentiality) • Article 14 Freedom from discrimination * Qualified Rights. Derogation is permitted but any action must: be based in law, meet Convention aims, be non-discriminatory, necessary in a democratic society and proportionate. 20

21. Article 2 Right to life Article 2 Does not require the prolongation of life in all circumstances Non-resuscitation of a 19-month-old child severe disabilities & short life-expectancy, it was held that withholding life-prolonging treatment did not breach Article 2 because the decision was made on the basis of the child's best interests. Justice Cazalet in (NHS Trust v D & Others [2000] TLR 197)

22. Article 8 Respect for Private & Family life • Qualified Right • Limited by law & ‘Legitimate Aim’ • Interference necessary in democratic society • Interference must be proportionate • ‘Margin of Appreciation’ 22

23. Article 8 Respect for Private & Family life Diamorphine & Non-resuscitation of a Child with sever medical problems Glass V United Kingdom [2004] 1 FLR 1019 (ECtHR) (merits) 23

24. Article 8 Respect for Private & Family life • Diamorphine & Non-resuscitation of a • Child with sever medical problems • Interference was necessary in democratic society Glass V United Kingdom [2004] 1 FLR 1019 (ECtHR) (merits) 24

25. Article 8 Respect for Private & Family life • Diamorphine & Non-resuscitation of a • Child with sever medical problems • Interference was necessary in democratic society • Interference was proportionate Glass V United Kingdom [2004] 1 FLR 1019 (ECtHR) (merits) 25

26. Article 8 Respect for Private & Family life • Diamorphine & Non-resuscitation of a • Child with sever medical problems • Interference was necessary in democratic society • Interference was proportionate • Interference not prescribed by law as no court order Trust could have got court order therefore Breach Glass V United Kingdom [2004] 1 FLR 1019 (ECtHR) (merits) 26

27. CPR decisions The Common Law (Those with Capacity) 2. The Mental Capacity Act 2005 (Those without Capacity)

28. CPR DecisionsThe Common Law and Mental Capacity Act 2005 For Incompetent Patients: Doctor makes decision In Patient’s ‘best interests’ MCA 2005. S4 (1)

29. Best Interests? Butler-Sloss LJ ‘Best interests are not limited to best medical interests.’ * ‘Best interests encompasses medical, emotional and all other welfare issues.’ ** Thorpe LJ ‘In deciding what is best for the disabled patient the judge must have regard to the patient's welfare as the paramount consideration. That embraces issues far wider than the medical. Indeed it would be undesirable and probably impossible to set bounds to what is relevant to a welfare determination’ *** * Re MB (Medical Treatment) [1997] 2FLR 426 at 439 ** Re A (Male Sterilisation) [2000] 1 FLR 546 at 555 *** Re S (Adult Patient: Sterilisation) [2001] Fam 15 at 30

30. End of life DecisionsFor Incompetent PatientsMCA 2005 • Lasting Power of Attorney (S11) MCA 2005. May Make Medical Decisions Section 11 (7) (c)

31. End of life DecisionsFor Incompetent PatientsMCA 2005 • Lasting Power of Attorney (S11) • Court Appointed Deputy (S20) ‘The deputy may not refuse consent to the carrying out or continuation of life-sustaining treatment in relation to P, unless the court has conferred on the deputy express authority to that effect.’ MCA 2005. May Make Medical Decisions Section 11 (7) (c) May Not Refuse life-saving Treatment Section 11 (8) Unless specifically mentioned

32. End of Life DecisionsThe Common Law and Mental Capacity Act 2005 For Medical decisions if not competent • Relatives advise on what patient would have wanted • LPA or court Deputy can make decision ‘For CPR’ but not DNAR * * Unless the LPA specifically includes the refusal of life saving treatment

33. End of Life Decisions Common LawSanctity of Life not absolute Quality of Life Lord Goff said in the case of a patient in persistent vegetative state p 867: ‘The doctor who is caring for a patient cannot, in my opinion, be under an absolute obligation to prolong his life by any means available to him, regardless of the quality of the patient's life.’ Airedale NHS Trust v Bland [1993] 1 ALL ER 821

34. End of Life Decisions Common LawSanctity of Life not absolute CPR decisions & Quality of Life? Your perception of somebody else's quality of life may be very far from their perception

35. End of Life Decisions Common Law Futility Will not restart breathing/heart * * Re R (Adult Medical Treatment) [1996] FLR 99, HC Re J (A minor) (Wardship Medical Treatment) [1990] 3 ALL ER930, CA

36. End of Life Decisions Common Law Futility Will not restart breathing/heart * Is not practicable ** * Re R (Adult Medical Treatment) [1996] FLR 99, HC Re J (A minor) (Wardship Medical Treatment) [1990] 3 ALL ER930, CA ** Re D (1997) 41 BMLR 81

37. End of Life Decisions Common Law Futility Will not restart breathing/heart * Is not practicable ** Would not restore person to condition they would wish or would be intolerable *** * Re R (Adult Medical Treatment) [1996] FLR 99, HC Re J (A minor) (Wardship Medical Treatment) [1990] 3 ALL ER930, CA ** Re D (1997) 41 BMLR 81 *** Re J (A minor) (Wardship Medical Treatment) [1990] 3 ALL ER930, CA Airedale NHS Trust v Bland [1993] 1 ALL ER 821

38. End of Life Decisions Common LawSanctity of Life not absolute Futility Sir Thomas Bingham MR said at 809 ‘the mere prolongation of life is not necessarily in a patient's best interests; that the purpose of treatment or care is to bring about recovery, to prevent or retard deterioration in the patient's condition and to alleviate pain and suffering in body and mind; and that treatment that does not achieve any of these may be regarded as futile.’ Airedale NHS Trust v Bland [1993] 1 ALL ER 821

39. Common Law & CPR • Many cases for Resuscitation of infants • Little case law for adults * * Re R (Adult Medical Treatment) [1996] FLR 99, HC

40. Re R (Adult Medical Treatment) [1996] FLR 99, HC • Age 23 years. • Born with severe disability, recurrent fits • Recurrent GI problems with abdominal pain • No means of communication • Awareness of being cuddled

41. Re R (Adult Medical Treatment) [1996] FLR 99, HC • In Nursing Home but attended Day Centre • Doctors & Family wished to make DNAR order • Day centre staff disagreed

42. Re R (Adult Medical Treatment) [1996] FLR 99, HC • DNAR order upheld • Unlikely to succeed – Futile • Might do further harm - Futile • Poor quality of life – Futile

43. Circulars & Guidelines All Trusts must introduce a CPR policy taking account of published Guidelines NHS Executive. Resuscitation Policy. ( HSC 2000/028 ) Withholding and Withdrawing Life-prolonging Treatments: Good Practice in Decision-making. August 2002. www.gmc-uk.org/guidelines Decision relating to CPR. BMA, Resuscitation council & RCN October 2007. www.bma.org.uk/ethics

44. Refusals & DNAR orders

45. Autonomy & CPRRight to refuse or request CPR? • Principle of Autonomy • suggests you have a right to • Refuse or • Request CPR

46. Ethics of CPR Autonomy may conflict with Utilitarianism For example refusal of CPR may deprive person of opportunity to live. Conversely the insistence on receiving CPR by one person may deprive others of resources. Actions should maximise human happiness but autonomous actions cannot be considered without regard to their consequences. * * John Stewart Mill. “On liberty” (1982), Harmmondsworth: Penguin p68. 46

47. Autonomy & LawLegal right to refuse CPR Right to Refuse Treatment Competent informed patients may choose to accept all, some or none of the treatments available to them even if treatment is life saving. ‘for religious reasons, other reasons, for rational or irrational reasons or for no reason at all’Dame Butler Sloss in Re MB ‘A patient’s right of choice is not limited to decisions which others might regard as sensible’Lord Donaldson MR in Re T This will include CPR Re T (Adult: Refusal of medical treatment) [1992] 4 ALL ER 649 (CA) Re C Adult refusal of treatment. [1994] 1 ALL ER 819 Re MB (An adult: Medical Treatment) [1997] 2 FLR 426 (CA)

48. Autonomy & CPR • If Patient refuses CPR • To perform it is Battery • Necessity is No defense Re B (Consent to Treatment: Capacity) [2002] EWHC 429 (Fam)

49. Ethics of CPR • Right to refuse implies Asking Patient Principle of Autonomy

50. Ethics of CPR Presumption of wish for CPR Impossible to make decision on every patient Reasonable to assume a wish for resuscitation