John Williams is director of ethics and legal affairs at the CMA.
Canadian Medical Association Journal 1995; 153: 1641-1642
Abstract
Résumé
Introduction
What's different?
Guidance for physicians
Guidance for patients
Future steps
References
The joint statement published last year involved years of development by the CMA, the Canadian Hospital Association (now the Canadian Healthcare Association), the Canadian Nurses Association (CNA), the Catholic Health Association of Canada and the Canadian Bar Association.(1)
In that statement, however, the CNA's name was conspicuously absent because its Board of Directors had declined to adopt the final version. A further round of negotiations has remedied this problem, and the revised version is fully endorsed by all five organizations.
Top of document What's different?
The differences between the 1994 and 1995 versions of the joint statement are relatively minor. The provisions for informed consent and communication of decisions about resuscitation have been made more explicit, and the footnotes have been incorporated into the text. The guiding principles, categories of patients and recommendations concerning the provision and nonprovision of cardiopulmonary resuscitation (CPR) are unchanged.
Top of document Guidance for physicians
The primary purpose of the updated statement is to provide guidance for the development of institutional policies for the appropriate use of CPR. Many institutions already have such policies; some have updated them recently, and others are doing so now. They set the ground rules for decisions on individual cases in which resuscitative intervention is an issue. To the extent that these policies incorporate the elements of the joint statement, all involved parties will have a better understanding of their respective rights and responsibilities.
For physicians, the rights include clinical autonomy in diagnosing the patient's condition and prognosis and recommending a particular course of action. The leader of the patient care team is usually a physician. Although the final decision about resuscitation is made by the patient or an appropriate proxy, physicians have the right to refuse to perform procedures they consider unethical.
A good institutional policy helps physicians by delineating the roles nurses, social workers, other health care professionals and clinical ethics committees play in decisions concerning resuscitation. Physicians need not feel overburdened by the responsibility they bear for such life-and-death matters; other members of the patient-care team are equally or more involved in these decisions, and the burden is shared.
The guiding principles of the joint statement are applicable to all patient-physician encounters, not just those involving decisions about CPR. They provide a useful summary of the expectations that patients have when dealing with their physicians, expectations that reflect the requirements of both ethics and the law.
Top of document Guidance for patients
The joint statement is intended to reduce the incidence of unwanted resuscitative interventions while ensuring that CPR will be administered when it is desired by the patient and is potentially beneficial. Many people are of two minds about CPR. On the one hand they appreciate how it can restore life and health to those on the brink of death. On the other, they are horrified by stories of terminally ill people having their chests hammered and tubes inserted in order to prevent desired death.
Although studies have shown when CPR is likely to be effective and ineffective,(2,3) the uniqueness of each patient's situation dictates that decisions about the use of resuscitative interventions must be made by and for each patient.
Policies can outline the factors that must be considered when making these decisions, but they cannot preclude the need for case-by-case decision making. Two patients with identical conditions may have very different views on whether CPR is desirable if the need arises. Because of a host of factors, patients can and do change their minds about CPR. Their views should be reassessed periodically and any changes should be communicated to everyone involved in their care.
Patients, family members and other proxy decision makers should be made aware of institutional policies on resuscitative interventions so that they will know what choices they have in this matter. Policies should encourage communication about the benefits and burdens of CPR so that patients can make an informed choice about whether and in what circumstances they would want it for themselves. They should be reassured that their decision will be respected.
The joint statement recognizes the utility of advance directives in determining an incompetent patient's wishes concerning resuscitation. Physicians will face more and more patient requests for help in writing advance directives. When it comes time to implement the directives, physicians need to determine if they are still valid or if circumstances have changed to the point where other factors must be considered in deciding whether or not to attempt resuscitation.(4) Some provinces have implemented legislation to deal with this issue, but individual discretion is still required.
Top of document Future steps
Publication of the updated joint statement is just the first step in changing public expectations and professional practices concerning CPR. The aim is to ensure that it is administered only when desired and potentially beneficial, rather than automatically unless a do-not-resuscitate order has been written. The sponsors of the joint statement are prepared to help institutions develop educational programs for health care professionals and patients, family members and the public. They are also cooperating in the production of a pamphlet on resuscitation that physicians and health care institutions can make available to patients and others who desire basic information.
The joint statement does not provide answers to all the issues associated with resuscitative interventions. One hotly debated topic is futility. Some feel that futility judgements are entirely subjective and should not be dealt with in general policy directives.(5) Others hold that there are objective standards by which potential interventions such as CPR can be judged futile or beneficial.(6)
Given the importance of this topic, the sponsors of the joint statement organized a symposium at the annual conference of the Canadian Bioethics Society. Held in Vancouver Nov. 23-25, the topic was, "Is there a place for `futility' in resuscitation policies?". The goal was to help the sponsoring organizations decide whether a model futility policy should be developed to accompany the joint statement.
Other issues also need further discussion. What is the role of proxy decision makers? How should advance directives and CPR be used outside health care facilities? The ethical literature on these topics is already extensive and growing rapidly, and there are numerous uncoordinated legislative initiatives under way in several provinces.
Physicians and their patients are understandably hard pressed to know their respective rights and responsibilities in these matters, and consensus statements like the Joint Statement on Resuscitative Interventions are much in need. The CMA welcomes members' comments on the joint statement and suggestions for work on related issues.