Appendix: Guidelines on Do Not Attempt CPR Decisions

Appendix Guidelines on Do Not Attempt CPR Decisions Cyrus Rustam Kumana Cardiopulmonary resuscitation (CPR) is treatment directed at restarting the heart soon after a cardiac arrest and/or interrupted breathing, and was introduced in the 1960s. Cardiac arrest refers to the abrupt cessation of an effective heart beat (typically as a result of ventricular fibrillation or cardiac asystole) and is often associated with an acute myocardial infarction. Moreover, from the patient’s perspective, this treatment is only offered if it can be presumed that recovery from such a cardiopulmonary arrest can enable at least a reasonable quality of life. When appropri- ate, however, it may also involve buying time for the harvesting of organs. Thus, the decision on whether to initiate CPR is a serious responsibility requiring careful appraisal of the patient’s medical problems, his or her personal wishes and those of the family, and awareness of relevant cultural and other issues. Communicating with patients and those closest to them about such very sensitive and potentially distressing matters therefore requires careful con- sideration and tact, needs to be timely, and should be entered in the medical record. The guidelines that follow apply to the management of seriously ill patients in whom cardiorespiratory arrest is anticipated, and are largely consistent with recommendations in recent publications of the Hong Kong Hospital Authority and the British Medical Journal.

392 Appendix 1. Summary Their purpose is to enable clinicians to arrive at professionally and ethically sound resuscitation decisions, which will safe- guard the best interests of the patient and the clinician. The aim of CPR is to restore cardio-respiratory function, whilst recognizing that it does have the following limitations: ¢ The process which leads to the arrest may be irreversible and/or the patient’s pre-arrest functional state is poor. » It may restore cardio-respiratory function without averting the neurologic sequelae of hypoxia. ¢ It may inflict pain, discomfort, trauma, and complications. Before arriving at a decision, clinicians need to consider a number of ethical principles which include the following: * Beneficence. * Non-maleficence. Patient autonomy. ¢ Medical futility. ¢ Non-abandonment. . Treatment decisions about potential resuscitation interventions should be based on: * The patient’s medical condition. e The overall treatment plan. * The likelihood of the patient benefiting from the resuscita- tion intervention. * The patient’s expressed wishes. . The issue of in-hospital resuscitation decision should be raised for all seriously ill patients in whom cardio-respiratory arrest is anticipated. Such decisions should be properly communicated to the patient and/or family, whichever is appropriate. . In arriving at a resuscitation decision, the process should be ini- tiated by the doctor-in-charge in conjunction with his/her team members, and should be documented and reviewed at regular intervals or when there is a significant unexpected change in the patient’s condition.

Appendix 393 Introduction The purpose of medicine is to save life and to relieve suffering. Thus, at times there may be a need for redirection of care from futile medical treatment to patient comfort-orientated terminal care. Given the limitations and potential harm of cardiopulmonary resuscitation (CPR) in the irreversibly dying patient and the practi- cal difficulties that may be encountered by front line staff, there is aneed to formulate specific guidelines on resuscitation decisions. Whilst these guidelines can assist all clinicians managing patients in whom cardiac or respiratory arrest is anticipated, they do not cover decision areas other than CPR. Why are guidelines needed? 1. To share among health care professionals the ethical principles involved in administering or withholding resuscitation. . To safeguard the rights of patients. 3. To establish a code of professional conduct in the practice of resuscitation. 4. To facilitate communication on the issue of resuscitation among caregivers and between caregivers and the patient/family. o What is cardiopulmonary resuscitation (CPR)? CPR is an emergency medical intervention for patients developing sudden cardio-respiratory arrest with the goal of restoring cardio- respiratory function. In a hospital setting and sometimes even in community settings, it is understood to include the support of breathing through intubation and positive pressure ventilation, and the support of circulation through chest compression, defibrilla- tion, and use of certain drugs. In the event of a cardio-respiratory arrest in the hospital setting, CPR is invariably administered unless there is a pre-existing decision by the care team to withhold it.

394 Appendix Limitations of CPR 1. If the process which leads to the arrest is irreversible or if the patient’s pre-arrest functional state is poor, CPR may be medi- cally futile in restoring cardio-respiratory function. 2. CPR may restore cardio-respiratory function but may not avert the neurologic sequelae of hypoxia known to be associated with cardiac arrest. 3. CPR may inflict pain, discomfort, trauma, and complications, and confers indignity during the patient’s last moments of life. Ethical principles related to CPR decisions 1. Beneficence: To preserve life, to restore health, to relieve suffering, and to limit disability. 2. Non-maleficence: Above all, do no harm. 3. Patient autonomy: To respect the right of the competent individual to make an informed choice to consent to or to refuse any clinically indi- cated medical treatment, including life-saving or life-sustain- ing treatment. In order to help the competent adult make an informed decision, the doctor has the responsibility to fully and honestly inform him/her of the nature of the disease, its prog- nosis, and the risks, benefits, and likely outcomes of various treatment options. 4. Medical futility: Doctors are not obligated to provide medically futile therapy when asked to do so by the patient or patient’s family. However, the term “medical futility” is subject to various definitions and interpretation. Medical futility in performing CPR in the strict- est sense refers to a lack of reasonable hope in restoring or sus- taining cardio-respiratory functions. The clinical decision on resuscitation for this category of patient is normally made by the doctor-in-charge, based on his/her clinical judgement. In other

Appendix 395 clinical situations, CPR can also be considered medically futile if there is no hope of restoring the patient to a quality of life which can be valued by the patient. However, such “quality of life” is subjective and interpretation varies depending on the patient, the family, and the doctor. The clinical decision on resuscitation in such situations should be supported by the patient and the family. 5. Non-abandonment: Doctors are obligated to provide a continuous caring partner- ship with the patient, which may begin in health or in sick- ness, last through potential recovery or adjustment to chronic illness, and often continues to death. CPR as a treatment option and resuscitation decision Treatment decisions about potential resuscitative interventions should be made based on the patient’s medical condition, the overall treatment plan, the likelihood of the patient benefiting from the resuscitative interventions, and the patient’s expressed wishes. Such decisions should preferably be considered and made before the need for intervention arises or a crisis occurs. In particular, the issue of resuscitation should be raised for all seriously ill patients in whom cardio-respiratory arrest is anticipated. Based on research studies on clinical outcomes of CPR, patients can be categorized into four groups depending on how likely they are to benefit. 1. Patients likely to benefit: There is a good chance that CPR will restore cardio-respiratory function and that restored function will be maintained. CPR should be administered to these patients when needed. 2. Patients for whom benefit is uncertain: The patient’s condition or prognosis or both may not have been assessed before the arrest. It is unknown or uncertain whether

396 Appendix CPR will restore cardio-respiratory function. CPR should be administered to these patients when needed. . Patients unlikely to benefit from CPR: There is little chance that CPR will restore cardio-respiratory function and even if function is restored, it is unlikely to be maintained. For these patients, an anticipatory discussion with patient/family on the limitations of CPR, as well as on life goals, values, and preferences is needed. The decision should be made based on the patient’s best interests and should be sup- ported by the patient and family. Patients who almost certainly will not benefit from CPR: There is almost no chance that the patient will benefit owing to the underlying situation. For these patients, CPR is not a treat- ment option. Some clinical situations where CPR is unlikely to benefit the patient 1. Advanced, progressive, inevitably lethal illness. 2. Acute, near-fatal illness without evidence of improvement after intensive support. Irreversible loss of major cerebral functions and extremely poor functional status. Communicating with the patient/family on CPR decisions . Good health care requires open communication and discussion among caregivers, patients, and family members. . The principle of patient autonomy should be respected if he/she is mentally competent. Determination of mental competence is made by the attending doctor in consultation with other caregivers. A competent adult

Appendix 397 is defined as one with decision-making capacity, which consists of the following elements: (a) The ability to understand the medical information presented. (b) The ability to reason and consider this information in rela- tion to his/her own personal values and goals. (¢) The ability to communicate meaningfully. 4. For a mentally incompetent patient whose wishes are not known, treatment decisions must take into account that individual’s: (a) Disease diagnosis and prognosis. (b) Known values, preferences, culture, and religion (often from those who are significant in the patient’s life) that may influence the treatment decision. 5. Important doctor attributes, which may facilitate communica- tion with the patient/family when discussing the resuscitation decision: (a) Adopting an open, sincere, and empathetic attitude. (b) Being a good listener. (c) Being sensitive to the feelings of the patient/family and not being unnecessarily antagonistic towards them. (d) Approaching the subject of resuscitation in stages to better prepare the patient/family. (e) Explaining the facts and considerations clearly, using easy- to-understand terms. 6. The contents of any communication should include but not be limited to the following aspects: (a) The patient’s condition in terms of diagnosis, extent of disease, prognosis, treatment options, chance of recovery, quality of life, and the chance of going into cardio-respira- tory arrest. (b) The patient and family’s expectations, values, and preferences. (c) What CPR entails and its goals and limitations. (d) The likelihood of the patient benefiting from CPR. 7. Communication should preferably take place in the presence of another member of the medical/nursing staff.

398 Appendix How to arrive at a resuscitation decision 1. The process should be initiated by the doctor-in-charge in con- junction with his/her team members. 2. Consideration should be given to the individual patient, in accordance with the principles listed 1-7 in the previous section. 3. The medical team should act as the patient’s advocate; all con- siderations must reflect his/her best interests. 4. The decision, the communication process, and the patient’s and/or family’s wishes should be documented in the medical records to ensure that all the patient’s health care providers are aware of the decision and will respect it. 5. The resuscitation decision should be reviewed at regular inter- vals or when there is a significant unexpected change in the patient’s condition. 6: A doctor’s recommendation should be supported by another doctor, where appropriate. Other care and treatment A decision not to initiate CPR does not imply withholding or with- drawing of any other treatment/ intervention. A patient who will not receive CPR should receive all other appropriate treatments, including other life-saving measures and palliative care. Conclusion These guidelines are intended to provide the conceptual frame- work for resuscitation decisions. In case of doubt, the attending clinician is advised to consult other peer clinicians or hospital ethics committees.

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