Questioning Medical Ethics in "Saving" Lives

"This is about invasive, aggressive, expensive life-sustaining treatments, used against people's wishes."
"Most people's concept of the dying moment is a tender moment, a warm moment, the family around you, holding your hand, preserving dignity. The reality for people undergoing resuscitation is the opposite of that."
"There's a real failure on our part to engage these older patients ... to honestly elicit their wishes."
Dr. Daren Heyland, critical-care physician/Queen's University professor

"Then when you sit down and have an open and direct conversation about it, you find out that's not what they want at all."
Dr. Stephen Workman, critical care specialist, QEII Health Sciences Centre, Halifax

"The big, long tradition of not really working with families is still very, very deep."
Sholom Glouberman, founder, Patients Canada (advocacy group)

Getty Creative   Issues over end-of-life care — from euthanasia to deciding when to stop life-preserving treatment — have been drawing attention recently like never before

A new study published in the journal BMJ Quality and Safety points out among other disturbing facts, that over a third of elderly and gravely sick patients who are hospitalized have been selected routinely to receive cardiopulmonary resuscitation whether or not they have indicated that they want the application of this generally-agreed futile measure, given their health condition. Logic might have it that something of this vital nature would be discussed between the attending physician and the patient on admission to hospital or at some time before the perceived need to take such action arises.

The authors of the report consider these orders that appear longevity-unwarranted -- to impose on gravely ill elderly patients a procedure that is both painful and futile -- represent a 'medical error' resulting from lack of communication. According to Dr. Heyland, who headed the research project that informed the paper, attempts to restart an arrested heart only on rare occasions save someone's life. What these attempts do in more real terms is impose on the helpless unneeded violence at a time when they really need a tranquil passage from life to death.

Over 800 patients were interviewed by the researchers, along with 600 members of their families at sixteen hospitals across Canada. Among other questions, the critical one of whether the patient would wish CPR to be performed on them (chest compressions meant to restart the heart and keep the patient alive in the wake of a cardiac arrest)was posed. With the response noted, the researchers looked at the patients' bedside charts to determine whether they were compatible with the stated wishes of the patients themselves.

For the large majority of patients -- most of whom were in their 80s with four in ten having congestive heart failure, advanced cancer or end-stage dementia -- who expressed a wish not to have CPR, 35 percent of the charts expressly indicated "full code" or made no mention of CPR, both of which amounted to the same outcome; to use all methods to restart the heart. On the other hand, the study found evidence that eight percent who said they would wish CPR had the opposite written on their charts.

Fotolia Some doctors hide behind euphemisms because they’re afraid of upsetting families or simply unsure of the prognosis, one physician says

Up to two percent of patients undergoing cardiopulmonary resuscitation in hospital live to see another day at home. Half of that number come out of the experience with serious neurological damage ensuing as a result of the application of CPR. Most of those interviewed stated they had not informed medical staff of their preference and for the simple reason that they were not asked. The truth is, people on both sides of the equation, health service providers and the public alike, prefer to skirt the issue of unpleasant end-of-life issues. And this is to the detriment of both.

Dr. Workman in Halifax felt the default position used throughout health care practise places any patient in full code unless their chart states otherwise. He feels this is a fall-back negating the need of medical practitioners to broach an uncomfortable subject; both for themselves and the public. But unless the chart reflects the patient's specific position the obligation of health professionals to act in a manner consonant with a patient's wishes cannot result.

Increasing numbers of people are now looking after their sick and elderly family members. They are themselves quite reluctant to speak of such matters when they feel they are reflecting their loved one's best interests and wishes for themselves about when life-sustaining treatment should stop, advises Mr. Glouberman of the Patients Canada advocacy group. This is, of course, a matter affecting people everywhere, not just in Canada; an issue long overdue for a system of best-practise to be adopted.