Sunday, May 25, 2014

CPR Without Consent

Agnes was out shopping at her local corner store.  At age 82 her body was beginning to show typical signs of aging.  She had survived breast cancer surgery, a hip replacement, and cataract surgery.  Her doctors told her she had osteoporosis and low Vitamin D.  She took medications for her hypertension, cholesterol, and osteoporosis.  Her spine had begun to curve and her gait was a few steps slower.  Yet, with her shopping cart she still enjoyed her trips to the store.  Her best friend had suffered a cardiac arrest recently and didn't survive the hospital stay.  She discussed this with her retirement home personnel and decided she never would want CPR.  A "Do-Not-Resuscitate" order was initiated by completing a POLST form (Physician's Order for Life Sustaining Treatment).  She made copies of the POLST form giving them to her physician and retirement home staff.

While at the corner store, Agnes felt light headed and sat for a moment but then slumped to the floor.  Shoppers at the store immediately started CPR and 911 summoned the Medics.  With the standard 1.5 to 2" compressions of the sternum, multiple ribs were broken and the lungs were later found to be punctured.  Her heart rhythm was "shockable" and after 5 shocks, she stabilized and was taken to a nearby ICU.  The next few days were stormy both medically and ethically.  The hospital staff felt they had preserved a life, yet the family said she was ready to "pass on" and didn't want the heroic life support.  Finally the family and POLST form wishes prevailed and she was "allowed" to die in the ICU after the tubes were removed.

Comment:  Society generally prohibits us from medically or surgically treating a patient without their informed consent.  However society places, quite naturally, a high value on preserving life.  Since the 1960's CPR has been evolving and improving.  It has been popularized on multiple TV shows such as ER, where the survival rates approach 66%, much higher that the real word data (which continues to improve).

The "frail elderly" are a particular problem because the trauma of CPR may cause more harm than good in some individuals.  The statistics of young people don't apply to the elderly.  And many elderly just don't want CPR saying, "I've had a full life and having my heart stop wouldn't be a bad way to go."

Yet all of us are "signed up" for CPR, unless there's a really clear way to avoid it.  Some families simply don't call 911, some have POLST forms, or some spouses and caregivers are able intercept the process by demonstrating they have power of attorney for health care.

The American Bar Association has come up with a smart phone app to store advance directives and other medical data which might be helpful to the techie generation.  Some states have free registries and there is a fee based national registry for advance care documents, but finding these can be difficult in the acute situation.

The frustrating bottom line for the "frail elderly" is that very few of us have had an informed consent discussion about the pros and cons of CPR.  And even if we decide, "Heck, I'd never want anything like that", a lot can still go wrong in terms of knowing and respecting our wishes.  Even a "No Code" tattoo on your chest isn't legally binding!  So in addition to having "the conversation" with your doctor and loved ones, try to come up with a plan if you really want to avoid CPR.  One thought is to electronically store any POLST/DNR orders with 911 responders.  That way, when they are summoned, the orders will be immediately available.   This may a concept worth field testing.

4 comments:

  1. Is one lesson to take your POLST form with you to the grocery store? Would medics have looked for it on your person? Perhaps if she had some special jewelry that indicated the presence of a POLST? Or if the state had a e-POLST rgistry that could have been queried?

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    1. Thanks for the good ideas. The problem the lay person and medics have is that there is wide variation in the medical alert bracelets/necklaces, limited availability of POLST forms in a miniature readable size, and the acuteness of the situation. Also, there's the legal question as to whether the untrained lay person has the ability to read, interpret, and follow the POLST form (or bracelet). Unfortunately a lot of unwanted CPR will continue to happen until we have a more systematic approach. I did have one 90 year old lady whose family went to the fire station and gave a copy of her POLST to the 911 responders well ahead of the time they were eventually called. This one on one communication was effective in her case in averting CPR.

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  2. Just as there was PR to teach people that CPR can save lives, there needs to be a campaign to demonstrate it's dangers --- and to get most of the public aware upset to think that their personal wishes might no be honored.

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  3. This reminds me of one time in the ER with my frail,elderly mother when we didn't have our MOLST form with us. We asked to fill one out 'just in case' and the young intern kept badgering my mother to agree to CRP- even though she had a Living Will and previously completed MOLST form that explicitly stated against that act. At one point, I told her she was being cruel and that my mother could answer the questions without her intervention. At this point in my mother's life her chest would be completely broken by CPR and we're aware of the poor statistics of survival with quality of life for people in her condition. Hopefully, we'll soon has universal, digital records of these important documents.

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