Wednesday, November 14, 2012

"Slow and Show" CPR: Patient's Best Interest?

Cardio-pulmonary resuscitation (CPR) is the term used to describe the action of attempting to prevent a patient from dying from sudden stopping of heart beat or breathing.  CPR has been an accepted medical technique for decades and has been performed both on the outside and inside a hospital.  Within the hospital, it has been the policy over the years to provide CPR to all patients suffering cardiac or pulmonary arrest with few exceptions unless the patient has previously requested "do not resuscitate" (DNR) and this request placed as a physician's order in the patient's chart. 

Since, the time available for resuscitation to begin and have any chance of being effective and prevent death is only a matter of a few minutes at the most, CPR activity must begin promptly with a planned resuscitation protocol including the identification of a cardiac and/or pulmonary arrest event, arrival of medical personnel with necessary equipment and the prompt initiation of resuscitation actions by the staff with appropriate modifications depending on the patient's response.  Though not all resuscitation attempts are successful either to save the patient from death at the time, prevent persisting damage from the event or permit a live discharge from the hospital, without prompt and proper management, death will be the result.

Since CPR has been granted as default to all patients except those who have requested DNR there will be patients who arrest and thus a candidate for CPR who have terminal illnesses with no chance of a valued recovery even if death at this point is prevented.   But the question is "whose value?"  Should it be the determination of the medical staff or should it be that of the patient?  And when there is no DNR requested by the patient either because the patient wanted CPR or that the patient was not offered that alternative, should the medical staff be as energetic in initiating and performing CPR in a patient who the staff assesses as already terminal with unlikely long term benefit from that resuscitation attempt? 

Over the years of CPR, there has been a practice which has occurred in hospitals in which the medical staff having made their own prognosis of a futile life if the patient survives and may decide to not arrive as promptly as necessary to the stricken patient's bedside and when finally starting a CPR activity fail to perform it in an energetic fashion necessary for attempted benefit.  These responses have been titled "slow code" or even "show code" (only "showing" that something was being done but not really doing it with the goal of success.)  This practice has not been institutionally or professionally accepted over the years but is most likely still being carried out.  Why?  It is because since CPR is the default action in hospitals for all patients except those with a DNR order, there will be a number of patients who carry a poor overall prognosis and there will be physicians and nursing staff who recognize this and  find it difficult to be more energetic toward these patients in response to an arrest.  The ethical issue is whether this response by the professionals is really in the overall best interest of their patient or whether the patient should have had an opportunity to make their own informed decision in advance and that decision fully, completely followed by the staff irrespective of the professional prognosis.

The other, alternative approach to encourage patient decision-making would be to completely reverse the hospital policy: all patients and families would be notified on admission that CPR is no longer offered as a treatment unless specifically requested by the patient. There will be no DNR request needed. After all, CPR was originally begun as a treatment only for those in good health but with a sudden unexpected loss of heart beat or respiration through an accident such as electric shock or drowning.

What do you think about the CPR-DNR issue for hospitalized patients and about any persistent practice of "slow" or "show" codes?  ..Maurice.