Transcript CPR in old patients in hospital: is it futile?

CPR in old patients in hospital:
is it futile?
Dr Paul Diggory
Consultant Physician, Elderly Care Medicine and
Orthogeriatrics
Mayday University Hospital, London
Cardiopulmonary Decisions
Futile procedure ?
When should a DNAR order
be considered?
1.
2.
3.
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
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
Effectiveness of CPR
 Recognise arrest Rapidly
 Adequate CPR team
 Training in CPR
 Equipment / drugs
Effectiveness of CPR
(In Hospital Arrests)
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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
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.
Prognostic Scores
To predict those who will NOT survive CPR
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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
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.
Important CPR Issues
Why make a decision
 Time spent on patients who will not survive
Important CPR Issues
Why 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
Important CPR Issues
Why 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
Problems with CPR
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
CPR decisions
Increasingly under scrutiny
CPR decisions
Increasingly under scrutiny
 Legal Problems
CPR decisions
Increasingly under scrutiny
 Legal Problems
 Ethical Problems
How might the Law apply to
cardiopulmonary resuscitation decisions?
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)
European Law
(Human Rights Act 1998)
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Article 2.
Right to life
(Death penalty, self defense, just war)
 Article 3.
Not to be subjected to torture
(Inhuman or degrading treatment)
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Article 8.*
Respect for private & family life
(Confidentiality involvement of relatives)
 Article 9.*
Freedom of thought & Conscience
(Treatment on basis of religion/moral beliefs)
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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.
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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)
Article 8
Respect for Private & Family life
Qualified Right
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Limited by law & ‘Legitimate Aim’
Interference necessary in democratic society
Interference must be proportionate
‘Margin of Appreciation’
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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)
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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)
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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)
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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)
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CPR decisions
1.
The Common Law
(Those with Capacity)
2.
The Mental Capacity Act 2005
(Those without Capacity)
CPR Decisions
The Common Law and Mental Capacity Act 2005
For Incompetent Patients:
Doctor makes decision
In Patient’s ‘best interests’
MCA 2005. S4 (1)
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] 2 FLR 426 at 439
** Re A (Male Sterilisation) [2000] 1 FLR 546 at 555
*** Re S (Adult Patient: Sterilisation) [2001] Fam 15 at 30
End of life Decisions
For Incompetent Patients
MCA 2005
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Lasting Power of Attorney
MCA 2005.
May Make Medical Decisions
(S11)
Section 11 (7) (c)
End of life Decisions
For Incompetent Patients
MCA 2005
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Lasting Power of Attorney
Court Appointed Deputy
(S11)
(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
May Not Refuse life-saving Treatment
Unless specifically mentioned
Section 11 (7) (c)
Section 11 (8)
End of Life Decisions
The Common Law and Mental Capacity Act 2005
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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
End of Life Decisions
Common Law
Sanctity 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
End of Life Decisions
Common Law
Sanctity 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
End of Life Decisions
Common Law
Futility
1. 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
End of Life Decisions
Common Law
Futility
1. Will not restart breathing/heart *
2. 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
End of Life Decisions
Common Law
Futility
1. Will not restart breathing/heart *
2. Is not practicable **
3. 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
End of Life Decisions
Common Law
Sanctity 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
Common Law & CPR
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Many cases for Resuscitation of infants
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Little case law for adults *
* Re R (Adult Medical Treatment) [1996] FLR 99, HC
Re R
(Adult Medical Treatment) [1996] FLR 99, HC
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Age 23 years.
Born with severe disability, recurrent fits
Recurrent GI problems with abdominal pain
No means of communication
Awareness of being cuddled
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
Re R
(Adult Medical Treatment) [1996] FLR 99, HC
DNAR order upheld
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Unlikely to succeed – Futile
Might do further harm - Futile
Poor quality of life – Futile
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
Refusals & DNAR orders
Autonomy & CPR
Right to refuse or request CPR?
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Principle of Autonomy
suggests you have a right to
Refuse or
Request CPR
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.
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Autonomy & Law
Legal 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)
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)
Ethics of CPR
 Right to refuse implies Asking Patient
Principle of Autonomy
Ethics of CPR
Presumption of wish for CPR
Impossible to make decision on every patient
Reasonable to assume a wish for resuscitation
Practicality of
CPR
Generally no decision means
resuscitation if arrests
Practicality of
CPR
Generally no decision means
resuscitation if arrests
If no CPR decision has been made but it is obvious that
resuscitation inappropriate or will not work a decision
of medical/healthcare staff to abandon or not
commence CPR should be supported.
(BMA/Resuscitation guidelines 2007)
Ethics of CPR
 Right to refuse implies Asking Patient
Principle of Autonomy
 We Need to discuss if Foreseeable
If not asked no Autonomous decision possible
Autonomy & CPR
Majority of Elderly patients
would not wish CPR *
If at ‘Foreseeable Risk’ of Arrest
Guidelines suggest should ask
*
“The influence of probability of survival on patients’ preferences regarding
cardiopulmonary resuscitation.” N Eng J Med 1994; 330: 545
“Brain Resuscitation Clinical Trial II Study Group.” (1991) 32 N Eng J Me 1225
“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
Make CPR Decision
“Foreseeability”
‘where competent patients are at
foreseeable risk of cardiopulmonary
arrest, or have a terminal illness, there
should be sensitive exploration of their
wishes regarding resuscitation.’
* Decisions relation to cardiopulmonary resuscitation.
A joint statement from the BMA, Resuscitation Council (UK)
and the Royal College of Nursing. October 2007
Make CPR Decision
“Foreseeability”
GMC End of life Guidelines
Para 84
‘Where a patient is already seriously ill with a
foreseeable risk of cardiopulmonary arrest, or
a patient is in poor general health and nearing
the end of their life, decisions about whether
to attempt CPR in particular circumstances
ideally should be made’
Withholding and Withdrawing Life-prolonging Treatments:
Good Practice in Decision-making. August 2002.
www.gmc-uk.org
Consent & Negligence
‘Foreseeable event’
Lord Bridge in Sidaway commented. *
‘I am of the opinion that the judge might in certain circumstances
come to the conclusion that disclosure of a particular risk was so
obviously necessary to an informed choice on the part of the
patient that no reasonably prudent medical man would fail to
make it. The kind of case I have in mind would be an operation
involving a substantial risk of grave adverse consequences, as,
for example, the 10% risk of a stroke….a doctor, recognising and
respecting his patient’s right of decision, could hardly fail to
appreciate the necessity for an appropriate warning.’
* Sidaway v Board of Governors of the Bethlem Royal & Maudsley Hospitals
[1985] ALL ER 1018 (HL)
Make CPR decision if:
CPR a ‘Foreseeable event’
 Not possible for all in hospital (Should be possible to refuse)
 Not Foreseeable for most
 Foreseeable for all Elderly acutely ill patients
 Foreseeable for all severely ill patients
Right to Insist on Treatment
Burke v GMC
[2004] EWHA 1879
Justice Mumby
Burke v GMC
Rights of Patients to insist on Treatment
Because he will become incompetent

Wished to make Advance directive
to receive treatment

Judicially review GMC Guidelines
'Withholding and Withdrawing Life-prolonging Treatments:
Good Practice in Decision-making.'
End of life decisions
GMC Guidance
The final decision is the doctors
No obligation to provide treatment
Withholding and Withdrawing Life-prolonging
Treatments: Good Practice in Decision-making.
August 2002. www.gmc-uk.org/guidance
Justice Mumby
Burke Appeal
No Right to Insist on a Treatment
Lord Philips MR
Para 31
‘Autonomy and the right of self-determination do not
entitle the patient to insist on receiving a particular medical
treatment regardless of the nature of the treatment. Insofar
as a doctor has a legal obligation to provide treatment this
cannot be founded simply upon the fact that the patient
demands it.’
Burke, R v General Medical Council & Ors [2005] EWCA 1003
Burke Appeal
Lord Philips MR
Para 51:
‘The doctor will describe the treatment that he recommends or, if there
are a number of alternative treatments that he would be prepared to
administer in the interests of the patient, the choices available, their
implications and his recommended option. In such circumstances the
right to refuse a proposed treatment gives the patient what appears to
be a positive option to choose an alternative. In truth the right to
choose is no more than a reflection of the fact that it is the doctor's
duty to provide a treatment that he considers to be in the interests of
the patient and that the patient is prepared to accept.’
Para 55
‘a patient cannot demand that a doctor administer a treatment
which the doctor considers is adverse to the patient's clinical
needs.’
Burke, R v General Medical Council & Ors [2005] EWCA 1003
No right to insist on CPR
Cardiopulmonary
Resuscitation
Patients should have the right
to choose not to be for CPR
Re T. (Adult Refusal of Treatment) [1992] 4 ALL ER 649 (CA)
Re B (Consent to Treatment: Capacity) [2002] EWHC 429 (Fam)
Cardiopulmonary
Resuscitation
Patients do not have a right to
insist on a treatment that has
little prospects of success? *
* Burke, R v General Medical Council & Ors [2005] EWCA 1003
Ethics of CPR decisions
For Elderly Care Patients
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Patients Do not wish CPR*
Patients confuse CPR with treatment**
Patients find discussion distressing ‡
Patients can not understand
concept of risk Ф
* NEJM. 1994:330:545. RESUSCITATION 2003;56:159
** BMJ. 1994; 309:408
‡ Heart.2001; 86:626
Ф Ann Int Med. 2001;134:1120. Age Ageing 2001;30:473
The first question
Will it work?
Previous state not relevant
The second question
Does patient have capacity?
Do they have LPA or Deputy?
E.C. CPR Policy
If cognitively intact

If CPR might be successful
Ask patient if they would want it
E.C. CPR Policy
If cognitively intact

If CPR might be successful
Ask patient if they would want it

If CPR will not succeed
Explain that will not be offered
If likely to cause distress do not have to explain *
* Sidaway v Board of Governors of the Bethlem Royal & Maudsley Hospitals
[1985] ALL ER 1018 (HL)
E.C. CPR Policy
If Not cognitively intact

If CPR might be successful
Ask patient relatives or LPA if they would want it

If CPR will not succeed
Explain that will not be offered.
If no relative document DNAR
CPR Decisions
 If arrest ‘Foreseeable’ make decision
 If success possible & not confused
Then ask the patient
*
 If success possible & confused
Then ask relatives/LPA what patient would have wanted

If success unlikely make DNAR Order
Inform patient if not confused *
* If confusion or distress likely no need to discuss
CPR Decisions
When reviewing a patient
(Shared care on ward)
Any Change in the decision by another team should be supported
If nursing staff find patient in whom resuscitation is
clearly inappropriate:
A decision not to perform CPR should be supported.
BMA, Resuscitation council & RCN Guidelines October 2007
Questions?
Ignoring a DNAR order
Uncommonly, some patients for whom a DNAR decision has
been established may develop cardiac or respiratory arrest from
a readily reversible cause such as choking, induction of
anaesthesia, anaphylaxis or blocked tracheostomy tube.
In such situations CPR would be appropriate, while the
reversible cause is treated, unless the patient has specifically
refused intervention in these circumstances.
(BMA/Resuscitation council & RCN guidelines 2007)
Cardiopulmonary Decisions
Some clarity & freedom