by: Josh Lakin, MD Palliative Care Fellow, UCSF
This week has been full of active discussion around “the code”. As a malleable and growing fellow in palliative care, I believe that I have spent more time on the single intervention of CPR than I have eating breakfast over the past 300 and some change days. As such, the discussion around code status, what to call a code or a lack thereof, and the default with which the medical system presents our patients have been incredibly interesting for me.
But, as Diane Meyer, Rebecca Sudore, and Craig Blinderman all discussed in their replies to Alex Smith’s post from this week, possibly the more salient and controllable piece for care providers is the conversation around goals and how we recommend or don’t recommend therapies in light of those goals.
In that light, I would again like to call attention to the study that Craig brought up in his reply to Alex’s post . In that March 2012 JAMA thought piece, Craig, Eric Krakauer and Mildred Solomon laid out a practical 3 pronged approach for making recommendations around the medical intervention of CPR based on clinical assessment of its risks and benefits for a particular patient based on his/her disease and goals. Their three categories are as follows:
- Consider CPR as a Plausible Option – for situations where the benefits and risks of the procedure are unknown in the context of the patient. The example they use is for patients who have chronic illnesses that have not yet reached end stage. For this group, they recommend exploring and addressing patient beliefs around their disease and record patient preferences based on a “nuanced understanding of the patient’s’ values.”
- Recommend Against CPR – for situations where there is a low likelihood of benefit of CPR, such as in end stage advanced illness. In my experience this year, this group is the one for which Palliative Care is often called with the consult of “the patient just doesn’t understand his illness and his goals. He tells me he is ready to die peacefully but he wants CPR.” The authors’ key point here is to be able to keep an open mind for “unique personal, familial, religious, or cultural factors that might make an attempt at CPR unusually beneficial.”
- Do Not Offer CPR – for patients who are dying imminently. The authors then make the point that, in this situation, “the decision not to offer CPR should be disclosed to the patient or surrogate.”
As a learner, I find this framework especially helpful as it gives me a guide for my daily work and, maybe more importantly, it gives me a guide for teaching other trainees in the hospital who seem to lump everyone into the first category. However, I’ve been struggling this year to understand why we treat CPR so differently than other procedures, such as feeding tubes or surgery, where the decision neither to offer nor disclose seems to come more naturally. I have yet to find a satisfying legal, ethical, or scientific explanation for why that is so.
As such, I am still wrestling with the final point in option 3: that we still need to disclose our decision not to offer CPR. It seems that we frequently don’t disclose a common decision not to dialyze the patient dying of renal failure from complications of metastatic cancer, for example. So, why do we need to disclose the decision not to do CPR?
What is it about CPR that makes it so different from other procedures? At first I was thinking that it is the great risk incurred in not doing it. But then, one could make the same argument for hemodialysis or for exploratory laparotomy for bowel ischemia if you made the time frame just a bit longer from minutes to hours or a few days. Then I was thinking of the concern for causing regret for the patient or family later if they learn that it was an option and wish that it had been done. Again, I feel that deep regret could surface from the same realization around feeding tubes or dialysis. Maybe it is just a cultural norm in medicine to treat CPR differently from other therapies.
Clearly, as everyone I mentioned before pointed out, decisions around these interventions MUST be rooted in a process of gaining a solid understanding of patient goals and a thorough assessment of risks and benefits of the procedures and that remains the key imperative highlighted in this article and on this blog this week.
But, all that said, I am still at a bit of a loss: Why do we feel the imperative to discuss and/or disclose this procedure with those who will not benefit from it (barring “unique factors”)?
Or maybe the question could be turned around: Why don’t we always discuss and/or disclose decisions about other non-beneficial procedures, such as not offering dialysis to patients?
What is it that makes CPR different?
NOTE: This is one in a series of posts for “Code Discussion Week.” Here is a list of the rest:
- It’s all in the Framing: How to Influence Surrogates’ Code Status Decisions
- Changing the Default Code Stus to DNR for Seriusly Ill Patients
- The Clinician as the Choice Architect – Nudging an Informed Choice About CPR
- What Is A “Natural” Death, Anyway?
- Discussing CPR: What Makes It So Different?
- CPR Discussions and Harm Reduction
- When Not to Follow an Advance Directive