Canadian Medical Association Journal 1996; 154: 887-888
Dr. John Quinlan sent the accompanying letter concerning resuscitative interventions to the CMA's Department of Ethics and Legal Affairs. With his permission, CMAJ forwarded it to Dr. William Cook for a response. We thank both physicians for participating in this exercise.
The first involved a man of about 78 who was in reasonably good health till an asymptomatic abdominal aortic aneurysm was found by chance. It was operated on and successfully repaired.
About 36 hours postop, while still in the recovery room, he arrested. CPR successfully restored his heartbeat, but the patient failed to recover consciousness and for 3 weeks received the full vegetative treatment in the intensive care unit. He was then transferred to the palliative care ward, where a ventilator, respirator and total parenteral nutrition and hydration were maintained for another 3 weeks.
Was this 6 weeks of very expensive care a waste of hospital resources, or should the "plug have been pulled" after about the 3-week point, when he was obviously a vegetable?
The second patient was a 42-year-old man who had a history of two suicide attempts. He also had a wife and two small children. He had a classic coronary attack and was admitted to the coronary care unit. In the presence of one physician and two nurses, he stated that he did not want to be resuscitated if his heart stopped.
Let me outline two possible scenarios. He has a cardiac arrest, the staff on duty do not know of or have forgotten his "No Code" request, and they successfully resuscitate him. Unfortunately, they broke a rib while doing so - not a rare complication with CPR. He now has an air-tight case for charging assault.
The second scenario is the opposite. The staff know about the "No Code" request and do not act when he has a cardiac arrest. The man dies. The widow with two young children has an air-tight case for negligence on the part of those present because CPR is standard practice and it wasn't applied.
Both of these cases took place 7 or 8 years ago. The first patient was in to see me a few days ago, with no more than the routine complaints you would expect from an 85-year-old man. The second patient eventually recovered and has not made another suicide attempt or had another heart attack.
For me, there appears to be no answer to the ethical nuances raised by these two cases.
Yours sincerely,
John J. Quinlan, MD
The joint statement is meant to be a guide for policy approaches to resuscitative interventions and not an algorithm for decision making in individual cases. It is recognized that when dealing with individual cases, such as those you present, that even at the best of times it may not always be possible for everyone to feel satisfied with the decision(s) made. I presume this is what you meant by "cases where reasonable decisions about resuscitation were impossible to achieve."
Given your two cases and the concluding paragraph about the patients' present status, it would appear that reasonable decisions were indeed made, at least from the patients' perspective.
However, your cases and comments do draw attention to the difficulties we experience in making decisions regarding resuscitative intervention, and bring forward two questions. The first asks how, generally, might we approach these cases and ones like them; the second asks how the joint statement and its premises might help physicians.
Regarding the general approach to these cases, I accept the premise of clinical ethics that "the patient is the norm" (Roy DJ, Williams JR, Dickens BM: Bioethics in Canada, Prentice Hall Canada, Scarborough, Ont., 1994) and that the resolution to issues being faced will be found within the detailed particulars of the case itself.
This demands that an effort be made to get to know and understand the patient and the patient's "story" in its broad context, and to establish and maintain a dialogue among all concerned parties so that an acceptable consensus on how to proceed will develop. Often this will involve the explicit questioning of goals to be sought, values to be supported or not supported and benefits and burdens to be balanced, all within the context of the particular patient's medical condition, life goals, needs, wants and relationships.
What are the medical facts and expected prognoses? Is the patient competent to make decisions? Can the level of competency be enhanced and autonomy supported? What do we know about the patient's life goals, values and beliefs? Is there an advance directive, or do family, friends or others have knowledge regarding the patient that would help? Who should decide? What constitutes a benefit and a burden for this patient? What ethical principles are involved and how are they to be understood in this case? What policies or laws have a bearing on this issue? These are just some of the questions that must be explored.
I suspect, Dr. Quinlan, that even though you do not present the details in your cases, many of these questions were, in fact, asked. In your first case, even though the patient failed to recover consciousness after successful CPR and remained "vegetative" for 3 weeks in the ICU, he was transferred to the palliative care ward but still continued to receive full life-support treatment until, at some later point, there appears to have been a full recovery and several more years of contented life.
With the second patient, you do not say whether a DNR order was written and by luck and good treatment it was not called upon, or whether the patient's request was overridden, perhaps on the basis of a questionable level of competency given a presumed state of significant depression.
How would the new guidelines in resuscitative interventions help in these cases? The first case you presented concerned an elderly man who was undergoing elective major surgery for an abdominal aortic aneurysm. The new guidelines suggest that "treatment decisions about potential resuscitative interventions should be made within the context of discussions concerning the plan of treatment . . . [and] should be considered before the need for intervention arises or a crisis occurs" (CMA Policy Summary: Joint Statement on Resuscitative Interventions [Update 1995]. CMAJ 1995; 153: 1652A-1652C). At the very least, this provides an opportunity to discuss options and learn about patients' values, preferences and goals, information needed if decisions are to be made on their behalf should they become incompetent.
The guidelines also stress the importance of considering capacity to make decisions and the need to protect vulnerable incompetent patients. I believe your second case is centred around this issue, so no hasty decision on the patient's DNR request should occur until the competency issue has been sorted out.
The joint statement further stresses the need to ensure that all those involved in the patient's life and care engage in a broad dialogue through which acceptable resolutions are achieved. In my experience, such an approach is more likely to achieve the "reasonable decision" that you seek.
Yours sincerely,
William A. Cook, MD, FRCSC