MORAL
ISSUES TODAY
By
Mark Miller, CSsR
Do
your doctor a favour and talk about DNR orders
Those of you who have been
in hospital for a relatively serious surgery or dangerous illness have
probably experienced an encounter with your doctor/surgeon who comes
into your room carrying a file on a clip board. The doctor may have
then begun a conversation that went something like this:
Doctor:
I need to talk to you about a DNR order, a Do Not Resuscitate order.
May we spend a few minutes on this?
Patient:
Sure. What's a DNR?
Doctor:
Basically, I need to ask you what you would like us to do if your heart
stops. We have a procedure called cardiopulmonary resuscitation (CPR),
which involves two possible interventions. The first is chest compressions
by which the staff thump on your chest to see if your heart will re-start
as a result of the shock. Or, in some cases, we will use a defibrillator
which actually gives a shock through your chest to your heart, again
in the hope that it will re-start your heart. If your heart does not
re-start, you will be, in fact, dead.
Patient:
So, what are you asking me for?
Doctor:
Well, if you do not want us to try either form of CPR, you will die.
And there are many reasons why some patients would not want CPR attempted.
Some patients are terminal and ready to go. For many cancer patients
near the end, a DNR order is to protect them from what can be a very
damaging intervention while keeping the patient alive a bit longer for
the cancer to continue its work. And, sometimes, a heart stops unexpectedly.
Further, CPR, like all medical interventions, may have challenging side
effects. Chest compressions, when we thump on your chest, may cause
severe bruising (even to the heart itself), broken ribs or a broken
sternum — which you would have to recover from if your heart re-started.
Defibrillators, if not used quite right, may cause serious burns to
your chest. And if we cannot get your heart started relatively quickly,
the lack of oxygen to your brain may cause serious damage that could
be like a stroke or, in worst-case scenarios, leave you in an unconscious
or severely damaged state for the rest of your life. Consequently, we
have to ask you whether or not you would want this treatment.
Patient:
Aren't you supposed to make those decisions, doctor?
Doctor: I
wish it were that simple. When a person comes into the hospital and
we have not asked them what their wishes might be (or if they have an
advance care directive that tells us what they would want or not want
with respect to CPR), then we automatically call a Code and begin CPR,
regardless of the outcome. Because it can potentially save a patient's
life, we are not at liberty to refuse this treatment even where we,
as doctors, think it is highly inappropriate. For example, the success
rate for ordinary healthy people in the hospital is less than 50 per
cent. The more medical conditions you have and the more serious your
condition, the less likely it will be that CPR is effective. For the
elderly — say, those presently in long-term care homes, the success
rate is less than six per cent. And for the frail elderly, the success
rate is one per cent or less. And please notice that “success”
means we re-start your heart — it does not refer to the side effects
that may affect you either temporarily or for the rest of your life!
I personally think there are situations where CPR is inappropriate —
but unless we ask the patient we cannot be sure and we have to follow
their wishes if they refuse CPR or some aspect of it. (Some people will
accept a defibrillator but not chest compressions — for example,
because of osteoporosis and the damage they could incur). Regardless
of what I think, however, patients (or, hopefully, their substitute
decision-makers) are the only ones who know their own circumstances.
I recall a lady who was close to death due to cancer, but she wanted
CPR if her heart stopped within the next week because she expected her
daughter to have her first baby within days. For her the most important
thing in the world was to have time to say hello to her grandchild.
That is why we ask the patient.
Patient:
Wow! This is a difficult decision. Can I have time to think about it?
Doctor:
Certainly, but you need to know that until you give me an answer, if
your heart stops, we will try CPR.
I am never quite sure if
this is a more-or-less exact conversation between the doctor and the
patient. Some doctors are curt and just want an answer; others will
take time to talk with you. Still others tend to avoid the discussion
in the hope that it will go away, like when you are discharged! And
some doctors, notably those who care for the dying, have these conversations
all the time because it is uncommon for patients in palliative care
to want CPR attempted (though some do, for their own personal reasons).
The reason I am writing this column about CPR is because this conversation, in one form or another, should be held with every patient in a hospital. It is held with every resident who comes into a long-term care facility, because the staff need to know how to instruct the paramedics should the resident collapse and his/her heart stops. (I should also note that from my un-scientific experience of long-term care facilities, over 90 per cent of the residents do not want CPR performed — which is understandable, given the low success rate, and the potential complications.)
In hospitals, however, things can happen very quickly and staff members
who know clearly that you would want CPR will not pause even for a second
to wonder if you have been asked. Similarly, if the staff knows that
your wishes are clear — whatever the reasons — that you
do not want this medical intervention, then when your heart stops, everybody
knows that you have died.
Ethically, why would somebody refuse CPR? After all, it could save your
life. Well, go back over the doctor's conversation. There are many reasons
why a patient might refuse CPR. When one is old and frail, perhaps one
is ready to go and does not want any more treatments. When one is terminal
and at peace with God and loved ones, the last thing they might want
is the drama of a resuscitation attempt. Many people consider the low
success rate as a sign that when their heart stops, God is calling them
home; nobody needs to interfere. Recognizing the side effects —
especially potential brain damage and a severely compromised life —
may be reasons.
Interestingly, my conversations with some nurses who have performed
CPR over the years have yielded this response from them: I never want
CPR! It is too hard on the body; it is an indignity to the elderly;
it can lead to severe brain damage and I do not want to live like that
because some doctor thought he/she had to try and revive me; and (the
most interesting answer) some treatments are more like torture than
true care.
In the Catholic tradition, one has the moral right and obligation to
weigh the potential benefits of a particular treatment (offered for
your particular circumstances — so those are important) against
the potential burdens. And “burdens” are not just the physical
ones for they can include cost, consequences for your family, psychological
and even spiritual suffering. Do you know what your response might be
regarding CPR? It is something to think about because the doctor is
supposed to have this conversation with each patient. So, if you can,
come prepared and give the doctor a treat.
Miller is the provincial of the English-speaking Redemptorists of
Canada, based in Toronto, and working part-time for the Centre for Clinical
Ethics out of St. Joseph's Hospital in Toronto.
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