Sunday, May 26, 2013

CPR Discussions and Harm Reduction

"I Would Just Want a Few Shocks"

By: Bree Johnston

One issue that I think we have not examined sufficiently is the impact that repeated discussions about code status have on patients, family, and health care providers. I believe that repeated discussions about CPR are traumatic to the patient and family, erosive of trust, ineffective, and tend to distract the treating team from discussions and interventions that could be beneficial to patients and families.

I believe that is much more productive to think about harm reduction than to try to talk patients and their families them out of CPR. I agree with Blinderman, Krakauer, and Soloman that we need to think more actively about not offering CPR as an ethical option that is an appropriate path to harm reduction in some instances. This is the approach in the UK, and when I was there during the summer of 2010, I found that it was refreshing not to have to focus so much time on the code discussion.

Many hospitals have non-beneficial care policies in place in order to deal with patients and families who request non-beneficial care. In many institutions, the ethics committee must be called before this policy is invoked. In my experience, this policy is often used as a policy of last resort, and is not utilized often. I think that it may actually be kind to invoke these policies more commonly in instances in which families are traumatized by the burden of making end of life decisions.

Families feel a tremendous burden when making life and death decisions for a loved one. Depression, anxiety, and post-traumatic stress are common in such situations. Researchers have found that families facing end-of-life decisions in the ICU frequently desire more guidance than they actually receive. There is evidence that treating team support and communication can ameliorate some of the distress associated with the stress of having a loved one who is critically ill. In my experience, some family members are particularly traumatized by being the person who is “pulling the plug”. In these situations, taking some of the burden off of the family by taking the responsibility can be an act of kindness. When these policies are utilized, they will be most effectives if presented in a supportive rather than a paternalistic, heavy handed way. I say things such as “We want to offer all treatments that are likely to help you. In your situation, we think CPR won’t be helpful because it won’t reverse your underlying problem, and it is likely to cause more suffering. How do you feel about that?” In most, but not all, situations, that approach helps guide patients away from CPR who are unlikely to benefit.

Another avenue to harm reduction might be a short code (which Quill, Arnold, and Back discuss in their 2009 article in Annals of Internal Medicine). And I am finding that patients increasingly ask for limited resuscitation interventions, perhaps because of educational efforts around CPR or because of depictions of CPR on television. I find that commonly expressed sentiments include “I would just want a few shocks”, “just try to get me back and if it doesn’t work, let me go”, or “I want you to try – but don’t use machines. “

For much of my career, I have been frustrated at these requests. And I have heard many of my colleagues balk at these requests for “designer codes”. However, desire for a short resuscitation effort has some logic behind it. Outcomes are often good after short resuscitation effort, particularly if the patient has ventricular fibrillation/tachycardia. Many patients would want to be treated for these rhythms but would not want prolonged ICU care.

Any legitimate code must follow ACLS guidelines, and a short code is no exception. ACLS guidelines leave the duration of the code to the discretion of the attending physician and the code team. It is ethical to “call” a code after a reasonable amount of time if the interventions are not succeeding and the prognosis pre-code was dismal. A short code is not the same as a “show code” or a “slow code” – it is a legitimate resuscitation attempt, but an abbreviated one.

Unfortunately, a “short code” is not recognized as a legitimate request in most settings. Most order sets and POLST forms don’t have such subtleties written in – CPR decisions are black and white. For patients who have extremely poor prognostic characteristics who desire CPR, a short code may be a reasonable compromise if other avenues of harm reduction fail. It provides the patient and family with assurance that a potentially easily reversible condition won’t be neglected, but it minimizes the risk of initiating a prolonged ICU stay that is likely to be harmful to the patient and costly to society.

A challenge with the concept of a “short code” would be how to operationalize it. Any attempt to define a “short code” would be somewhat arbitrary, and should probably be debated if people think that the concept has merit. CPR survival goes down after 10 minutes, so that might be a reasonable cut-off. In addition, a “short code” might also be defined as one that is not associated with intubation, just support with airway positioning and ambu bag ventilation. Critical to the short code concept is that is defined, agreed upon, and used only in limited circumstances. In addition, the concept should be disclosed to the patient/family.

I look forward to an active debate on this!



NOTE: This is one in a series of posts for "Code Discussion Week."   Here is a list of the rest:

9 comments:

Bruce Scott said...

I haven't had great success in trying to communicate the difference between a short code and a slow/show code when speaking with resident physicians. The tendency is to think that both types are somehow fake and that the difference is largely semantic. My communication skills might not be up to the challenge, it seems.

mary t said...

Thanks for this post. I agree that this is a challenge -- and I believe a case can be made for a "short code"... Example: I was asked to see a 90 yr old man who wanted CPR, defib, but no intubation; he explained that a year before he'd gone into VFib (in an ICU) and had received defibrillation and recovered to have a good year. Hard to argue with that! If he'd had a DNR order, he would've died at that time; he was open to the same intervention, but if it wasn't effective, he didn't want further intervention.
It would be easier if these were black and white decisions; but this is where the art of palliative care comes in, I think, and keeps those of us working in the field striving to know how to help individuals get the best care at the right time...

Anonymous said...

It seems that the words we use when discussing DNR impact the decision more than patient/family preferences. Over 95% of the patients who die on our palliative care service have a DNR order at death - they are protected from non beneficial CPR.

Some patients/surrogates do want a resuscitative attempt at death. For those rare situations when a surrogate wants to know "something was tried" we may give an amp of epi or bicarb. We have found that a transparent discussion with surrogates and the medical team about this "attempt" is helpful. It reduces the moral distress associated with a futile code. Essentially, we are giving this amp of epi for the surviving family member but we are not calling a code team or performing non beneficial CPR. We write a DNR order but also write an order for the medication to be given at death. It is not really a "short code" but rather an "attempt at something" to ease survivor suffering.

Dana Lustbader MD

James Sinclair said...

I want to voice a provocative thought. We often talk about those rare occasions where a seriously and usually terminally ill patient is resucitated and survives with "quality" for some meaningful period of time. Would it be an absolutely wrong thing to happen if the patient had died and missed those extra weeks to months? I am sure if we tried to resucitate all of our hospice patients, a few would survive with "quality" life for weeks to months. Does that make it wrong to miss those weeks? Have we extinguished our fear of death?

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Laura said...

I agree with James. So sad that our society views death as unnatural and something to avoid at all costs. I think it is unethical to do fake codes. Did the author think about the consequences of the potential adverse outcomes of the code should the patient survive? There would be a greater risk of anoxic brain injury. When someone codes, do we really have time to dig through their medical records to figure out which parts of resuscitation they do or don't want? If they survive the code and are unstable, the usual course is that they are intubated (during the code) and transferred to the ICU. If they are DNI, does RT stay at their bedside bagging them 24/7? We need to think through these issues before trying to sell false hope to patients/families.

Do not resucitate said...

I think some of the problems would be solved if people discussed thier choices with thier families beforehand.

If someone does not want to be resuscitated, that is something they should firmly and plainly state to their families. They have to look at the total picture and the total responsibility before signing that order.

It should not fall on the physician to handle the family's guilt over doing all they can.

shehzad Amc said...

i think some of the problems would be solved if people discused their choices with their familys beforehand.
boca raton obgyn

Dr. B said...

Well written article! Thank you. I liked your wording on how you are not even offering resuscitation. What many forget is that we are legally not obligated to offer non-beneficial treatment to patients. If resuscitation is futile then it is clearly non-beneficial. It is also important to emphasize to the family that they are speaking with the voice of their loved ones and not actually making the decisions themselves... I think that helps to relieve any guilt or burden. A short code is an interesting point. I see what the 90 y/o patient meant and can agree with that (then of course it sounds like he has a great functional capacity to lead a meaningful life)... Why not make it clear: 10 min coding, no intubation and only ICU if circulation returns. It is a great compromise without leading to too many additional patients in the vegetative state. I think first and foremost we have to learn to accept that death is part of the equation! People die! Modern medicine may cure some disease and prolong our life with chronic illness but there is no cure for death! It would be great to return back to a "natural death". You have a wonderful blog here! Thank you! Dr. B PS: I just started a blog myself: http://geriatricmd.blogspot.com