Friday, May 24, 2013

Discussing CPR: What Makes It So Different?



by: Josh Lakin, MD Palliative Care Fellow, UCSF

This week has been full of active discussion around “the code”. As a malleable and growing fellow in palliative care, I believe that I have spent more time on the single intervention of CPR than I have eating breakfast over the past 300 and some change days. As such, the discussion around code status, what to call a code or a lack thereof, and the default with which the medical system presents our patients have been incredibly interesting for me.

But, as Diane Meyer, Rebecca Sudore, and Craig Blinderman all discussed in their replies to Alex Smith’s post from this week, possibly the more salient and controllable piece for care providers is the conversation around goals and how we recommend or don’t recommend therapies in light of those goals.

In that light, I would again like to call attention to the study that Craig brought up in his reply to Alex’s post . In that March 2012 JAMA thought piece, Craig, Eric Krakauer and Mildred Solomon laid out a practical 3 pronged approach for making recommendations around the medical intervention of CPR based on clinical assessment of its risks and benefits for a particular patient based on his/her disease and goals. Their three categories are as follows:

  1. Consider CPR as a Plausible Option – for situations where the benefits and risks of the procedure are unknown in the context of the patient. The example they use is for patients who have chronic illnesses that have not yet reached end stage. For this group, they recommend exploring and addressing patient beliefs around their disease and record patient preferences based on a “nuanced understanding of the patient’s’ values.”
  2. Recommend Against CPR – for situations where there is a low likelihood of benefit of CPR, such as in end stage advanced illness. In my experience this year, this group is the one for which Palliative Care is often called with the consult of “the patient just doesn’t understand his illness and his goals. He tells me he is ready to die peacefully but he wants CPR.” The authors’ key point here is to be able to keep an open mind for “unique personal, familial, religious, or cultural factors that might make an attempt at CPR unusually beneficial.”
  3. Do Not Offer CPR – for patients who are dying imminently. The authors then make the point that, in this situation, “the decision not to offer CPR should be disclosed to the patient or surrogate.”
As a learner, I find this framework especially helpful as it gives me a guide for my daily work and, maybe more importantly, it gives me a guide for teaching other trainees in the hospital who seem to lump everyone into the first category. However, I’ve been struggling this year to understand why we treat CPR so differently than other procedures, such as feeding tubes or surgery, where the decision neither to offer nor disclose seems to come more naturally. I have yet to find a satisfying legal, ethical, or scientific explanation for why that is so.

As such, I am still wrestling with the final point in option 3: that we still need to disclose our decision not to offer CPR. It seems that we frequently don’t disclose a common decision not to dialyze the patient dying of renal failure from complications of metastatic cancer, for example. So, why do we need to disclose the decision not to do CPR?

What is it about CPR that makes it so different from other procedures? At first I was thinking that it is the great risk incurred in not doing it. But then, one could make the same argument for hemodialysis or for exploratory laparotomy for bowel ischemia if you made the time frame just a bit longer from minutes to hours or a few days. Then I was thinking of the concern for causing regret for the patient or family later if they learn that it was an option and wish that it had been done. Again, I feel that deep regret could surface from the same realization around feeding tubes or dialysis. Maybe it is just a cultural norm in medicine to treat CPR differently from other therapies.

Clearly, as everyone I mentioned before pointed out, decisions around these interventions MUST be rooted in a process of gaining a solid understanding of patient goals and a thorough assessment of risks and benefits of the procedures and that remains the key imperative highlighted in this article and on this blog this week.

But, all that said, I am still at a bit of a loss: Why do we feel the imperative to discuss and/or disclose this procedure with those who will not benefit from it (barring “unique factors”)?

Or maybe the question could be turned around: Why don’t we always discuss and/or disclose decisions about other non-beneficial procedures, such as not offering dialysis to patients?

What is it that makes CPR different?



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

5 comments:

pvel said...

Josh: Excellent post. I also have been enjoying the flood of articles on how to approach the issue of CPR. And I have also wondered at times why it is that we feel the need to make a potentially worthless or harmful intervention something that must be offered, much less a default. We do not feel obligated to offer a 98 year old patient dying of advanced CHF a heart transplant, or guilty about witholding one...

Terry said...

This is a great question. As an experienced geriatrician the answer is because we have extrapolated "code status" so far from its simplistic intent (do or do not perform CPR). We use "code status" especially in long-term care as a proxy measure for how aggressively the patient "really" wants to be treated without acknowledging to ourselves as providers or our patients that we are doing this. Thus it gets to be uncomfortable to implicitly take "aggressive" treatment options off the table by labeling a patient DNR without their input.

Marian Grant said...

I agree this is a good question. Surgeons are the only providers I know who say no when someone isn't an appropriate candidate for surgery. And, although families sometimes struggle with that, it's usually final. Regarding CPR, I don't know if we are obliged to tell patients/families we're not offering but, if we are, I describe it as a potential harmful and ineffective treatment that the patient/loved one is not a candidate for. Some wise attendings and palliative care nurses taught me that!

Nicky Quinlan said...

great post. in reality many consults are "getting the DNR" ie the primary team feels CPR would be a harmful, futile exercise for a frail individual approaching the end of life and have had unsuccessful discussion (or no discussion) with the person and/or family to this end.
therefore we have an imperative to disseminate excellent primary palliative care early and longitudinally for care providers of individuals with serious illness. ideally this should have a solid foundation in the medical and nursing school curricula.

Anonymous said...

Great post that is the Tip of the Iceberg of the crazy culture that we call "Medical Practice." I am dumbfounded that we do to patients what we would not want for our own bodies. If a patient is actively dying this discussion just puts undue burden on the next of kin or the patient himself. It is often interpreted as "Do you want to die?" If death appears eminent I often acknowledge the issue but do not phrase it in a question form. To answer your question, I believe it is the ethics classes in medical school taught by non-clincal doctors (Ph.Ds) who never stepped into a hospital who have contributed to this craziness. Perhaps we can blame the TV programs where a person who undergoes a code-blue is back at home the next day, the legislators, lawayers, etc. There is a video available offered by a physician at Harvard Medical School which "Shows" patients what it is really like to be on "the vent" and most choose not to undergo such after they watch it....surprise.