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March 13th, 2013
Freethought San Marcos: CPR and End-of-Life Decisions

Freethought San Marcos: A column
by LAMAR W. HANKINS

 

Cardiopulmonary resuscitation – CPR – is as widely misunderstood as it is widely known, especially when it involves the terminally ill and those who are in poor physical condition.

The recent reports of the death of an 87-year old woman who was living in a facility in Bakersfield, California, have troubled many people.  The woman collapsed in the dining room of the facility, apparently as a result of cardiac arrest.  Staff called 911, but in keeping with the facility’s policy as they understood it, refused to give CPR to the woman despite pleas from the 911 operator to do so.  Emergency medical personnel declared the woman dead after they arrived at the facility a short while later.

Many nurses, at least one nurse’s association, and many lay people have viewed this refusal to administer CPR as criminal, or at least unethical.  Others have termed the failure immoral and unconscionable.  But the outrage may be misplaced and unwarranted.

Indeed, even as someone with twenty years experience studying, lecturing, and writing about end-of-life matters, my first emotional reaction was sorrow at the death of the woman.  I knew, however, that it was important to get all the facts before making any judgments about what happened.  The initial reporting was sketchy at best.  Now that more information has filtered out, we can draw more informed conclusions.  But first, it is useful to have basic information about CPR.

The Family Caregiver Alliance in California provides information, educates, does research, and advocates for those who provide care for the elderly and those nearing the end of life because of illness or disease.  The information it provides about CPR appears to be in the mainstream of medical knowledge about the procedure.  While CPR can have life-saving benefits for people in general good health who have certain kinds of heart attacks and accidents, especially in a hospital, it may be of little benefit to others.

The Alliance describes CPR far differently than it is usually portrayed on television: “Pushing the center of the chest down about one and one-half inches, 100 times a minute for several minutes, causes pain, and may even break ribs, damage the liver, or create other significant problems.  CPR produces a barely adequate heartbeat, and doing it more gently is not sufficient to circulate enough blood.  Electric shocks and a tube in the throat are also harsh treatments, but may be essential to resuscitate someone.”

Other organs that can be damaged by CPR include the spleen and lungs.  If CPR is only partially successful, so that normal breathing is not restored, it may lead to the need for a ventilator for days, weeks, months, or much longer.  When a person’s breathing or heartbeat fails for just a few minutes, the brain is deprived of oxygen and begins to fail, and permanent brain damage can result.

Studies about CPR have shown that only about 15% of patients in a hospital who receive CPR survive and are later discharged.  Fewer than 5% of elderly patients with serious illnesses who have CPR will leave the hospital alive.  The most likely beneficiaries of CPR are those with an abnormal heart rhythm, people who have respiratory arrest only, and people who are generally healthy.

Those with the least chance of survival from CPR are people with one or two medical problems, the frail and elderly, people who are dependent on others for care, and people who have long-term or terminal illnesses.

Some people, because of their physical condition or a permanent decline in the quality of life, decide not to have CPR if their heart fails.  All Americans have a constitutional right to make this decision.  The US Supreme Court, in the 1990 Nancy Cruzan case, recognized a constitutional right of an individual to make decisions about life-sustaining medical treatment and held that that right did not end if the person became mentally incapacitated.

Now, through advance directives, all competent adults can assure that their wishes are respected.  And our constitutional right to decide the kind of health-care treatment we want, before we need it, allows us to appoint a surrogate to make health-care decisions for us if we become incapable of making those decisions for ourselves.

While the Cruzan case clarified the law on end-of-life care, it also illustrates the tragedy of not having end-of-life medical care plans, no matter how young we are.  Cruzan was only 25 when she was seriously injured in a car accident and drifted into a persistent vegetative state.  Most people would not want to spend years in such a condition or suffer from other conditions that permanently make life impossible to enjoy and participate in.

But whatever your feelings about these matters, advance directives give all mentally competent adults a way to make their views known about these medical issues before they confront a serious medical problem.  Each individual who uses advance directives wisely controls such decisions.

Most states now provide statutory forms for both Directives to Physicians and Medical Powers of Attorney, but these forms may be expanded and revised to reflect a person’s precise wishes about medical care in the future.  People may draft their own directives if the state directive is inadequate to express their wishes.

In “Perspectives on Death and Dying,” authors Gere Fulton and Eileen Metress provide the history of such directives and explain that advance directives help ensure that a person’s “wishes concerning treatment options will be respected,” and “they protect . . . family members, health care professionals, and others from the stress and potential conflict of making critical decisions without sufficient information concerning (a person’s) wishes if (the person is) incompetent.”

Further, the federal Patient Self-Determination Act, signed into law in 1990 by President George H. W. Bush, requires all health care facilities and programs serving Medicare and Medicaid patients to establish written policies and procedures to determine their patients’ wishes about end-of-life care and to make sure these wishes are honored.  Such facilities and programs must also implement ways to educate their staff and community about advance directives.  As a result, most hospital patients are asked if they have advance directives when they enter the hospital.

To avoid unwanted medical services or assure that the ones you want are provided, everyone should discuss advance medical planning with physicians, family, and care-givers.  Such discussions may be organized around three legal documents, identified in most states as advance directives.  One form (called a “Directive to Physicians, Family and Surrogates” in Texas) allows mentally competent persons to decide what sort of medical interventions are appropriate for them if they are faced with certain medical conditions.  This form is sometimes termed a Living Will.

A second form provides for the appointment of a medical agent or surrogate to make medical decisions for a person if that person should become unable to make such decisions.  This form is called a “Medical Power of Attorney” in Texas, and is termed a “Durable Power of Attorney for Health Care,” or something similar, in other states.

The third form, which must be ordered by a physician in Texas at the request of a patient or medical agent is the “Do Not Resuscitate” (DNR) order.  This order can be used in a hospital setting or out of the hospital, in which case it is termed an out-of-hospital do not resuscitate order (OOHDNR).  This order provides that if a person’s heart stops beating, no efforts should be made to revive the person.  This decision is made by the patient, or the person’s agent if they are cognitively incapacitated, with the doctor’s agreement.

A few states have more comprehensive documents called “Physician Orders for Life-Sustaining Treatment” (POLST) or “Medical Orders for Life-Sustaining Treatment” (MOLST).  These are not available in Texas.

Since the story of the 87-year old woman first appeared, more information has come to light.  The woman was not in an assisted living center or nursing home, but in an independent living center.  It appears now that she had a stroke, not cardiac arrest.  And she was aware of and had agreed to the policy of the center where she lived – that CPR would not be performed in the event she collapsed.  The staff followed the agreed procedure and called 911 immediately.

The elderly woman’s family said she was aware that the facility did not offer trained medical staff, yet opted to live there anyway:  “It was our beloved mother and grandmother’s wish to die naturally and without any kind of life-prolonging intervention. We understand that the 911 tape of this event has caused concern, but our family knows that mom had full knowledge of the limitations of Glenwood Gardens and is at peace.”
Dr. Jennifer Black, a family and palliative medicine physician in Bakersfield, summarized the dilemma we all face: “(W)e must accept that death is an inevitable life event, not a medical problem that can be ‘solved’ with medicine, surgery or CPR. Next, we must learn the facts about CPR, and discuss these with our patients/doctors/loved ones. One of these facts: foregoing CPR is frequently not a matter of ‘letting’ someone die, but simply of minimizing the pain and suffering associated with an inevitable death. Finally, we must ensure that our patient’s — and our own — end-of-life wishes are known and clearly documented in an advance directive . . . . By doing these things, we can best assure wishes are respected, harm minimized and dignity preserved.”
A widespread discussion of this case may lead more people to have discussions with their physicians, families, and care-givers about their medical choices at the end of life.  If so, all the alarm, name-calling, and misinformation now being sorted out may help move more people to take charge of their end-of-life planning.

© Lamar W. Hankins, Freethought San Marcos
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LAMAR W. HANKINS is a former San Marcos city attorney.

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