CPR for patients in a persistent vegetative state?
CMAJ 1998;159:19
In response to: G.L. Crelinsten, et al; J. Turnbull; B.W. Jespersen; P. Walker; W.D. Gutowski
Patients and their families should be neither offered nor allowed to demand CPR in all situations. Empirical work has identified circumstances in which CPR cannot restore cardiopulmonary function.1 CPR may be withheld legitimately in such cases, and without the need to invoke the notion of medical futility, because it falls outside the standard of care for cardiac arrest.2 The patient in a PVS illustrates well the problem of medical futility. For these patients, the issue is not whether CPR is effective but rather whether the life is worth preserving. In my editorial, I argue that the joint statement3 errs in allowing a physician to override the religious or cultural beliefs of the patient and her family and to unilaterally withhold CPR from a patient in a PVS. Through my own work as a clinical bioethicist, I am aware of physicians and hospitals that have interpreted the joint statement as allowing such unilateral action. If, as the CMA Committee on Ethics claims, my criticism is based on a "serious misinterpretation," then they must agree that these physicians and hospitals are acting immorally. I am sorry they did not take the opportunity to state this more clearly.
When Dr. Turnbull wonders who will bear the cost of providing CPR to patients in a PVS, he confuses 2 logically distinct issues: futile treatments, by definition, ought not be provided even if there is a surplus of resources.4 In addition, resource allocation calls for an entirely different process than determination of futility, including an examination of cost-effectiveness data — he provides none — and community consultation. In the absence of such a process, a physician risks legal sanction if she denies available treatment to a patient on grounds of cost containment.5
Dr. Jespersen does not think the provision of CPR to a patient in a PVS is consistent with the primary goal of medicine, which is to provide benefit for the patient. Since a patient in a PVS is "irretrievably incapable of experience," she cannot experience benefit from CPR and, hence, it is "bad medicine" to provide it. But even if one accepts the premises of his argument — and I do not — the argument applies equally to all treatment, not just CPR. Thus, it would be just as unethical for a physician to provide a patient in a PVS with fluids by intravenous line or food through a feeding tube as it would be to provide CPR. If this is, as I suspect, inconsistent with the moral intuitions of physicians, then a new moral justification for withholding CPR from all patients in a PVS must be sought.
I am grateful for the support offered in the letters of Drs. Walker and Gutowski. Respect for the religious and cultural beliefs of our patients and their families is an indispensable part of good medicine.
Charles Weijer, MD, PhD
Bioethicist
Mount Sinai Hospital
Assistant Professor of Medicine
University of Toronto
Associate Member
Samuel Lunenfeld Research Institute
Toronto, Ont.
charles.weijer@utoronto.ca
References
- Bedell SE, Delbanco TL, Cook EF, Epstein FH. Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med 1983;309:569-76.
- Weijer C, Elliott C. Pulling the plug on futility. BMJ 1995;310:683-4.
- Joint statement on resuscitative interventions (update 1995). CMAJ 1995;153(11):1652A-C.
- Jecker NS. Futility and rationing. Am J Med 1992;92:189-96.
- Law Estate v Simice (1994), 21 CCLT (2d) 228 (BCSC), aff'd, [1996] 4 WWR 672 (BCCA).
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