The Last Act, Death Scene: Take 1 

You and the rest of your family are at Granny’s house, gathered around her bed. She’s dying. At ninety-two, she’s had a good innings. She’s ready to go. Her health has been declining for several years, which has been hard for Granny and you all because she was always so active. It’s her failing heart. She gets breathless on minimal exertion these days and has become housebound. She can’t manage her stairs and sleeps on a sofa bed in the lounge. Granny’s family doctor, who has known her for over thirty years, informed her several days ago that there’s nothing much he can do. Granny has accepted her fate. 

‘I’m not going into hospital when the time comes,’ Granny announced to all of you a few months ago. I want to die in my own bed, in the house where I’ve lived these past fifty-odd years, with my family around me.’ 

That time is now. Granny has pneumonia. She’s gasping for breath. The family doctor calls and concurs with Granny that her treatment should not be escalated. She won’t be admitted to hospital. He will prescribe her sedative medication to keep her comfortable. He signs a community DNACPR form. You all agree it’s for the best. 

Granny has a nice cup of tea, gives you all a kiss and quietly goes to sleep. All is calm. All is peaceful. All is quiet reflection and love. Granny doesn’t wake up. 

The Last Act, Death Scene: Take 2

You and the rest of your family are in the Medical Admissions Unit of the local hospital, gathered around Granny’s hospital bed. She’s dying. At ninety-two, she’s had a good innings. Her health has been declining for several years, which has been hard for Granny and you all because she was always so active. It’s her failing heart. She gets breathless on minimal exertion these days and has become housebound. She can’t manage her stairs and sleeps on a sofa bed in the lounge. Although Granny knows deep down that her time may be short, she finds it hard to accept. She hasn’t discussed her situation with anyone. It would be too upsetting all round.

When Granny goes down with pneumonia, a doctor who does not know Granny prescribes her antibiotics. Her condition worsens. By Saturday, she is gasping for breath and can hardly speak. Granny is taken to hospital. After a battery of blood tests, a chest X-ray and a CT scan, the diagnosis of pneumonia is confirmed. Granny receives intravenous fluids and more antibiotics. She becomes confused and doesn’t recognise any of her visitors, including you. The consultant looking after Granny asks to speak to you all. She tells you all that Granny is seriously ill and might not recover. She might die, in fact. The news comes as complete shock. Granny’s consultant, who is clearly a very experienced doctor, convinces you all that attempts to resuscitate Granny, should her heart stop, would be futile. Accordingly, she signs a DNACPR form. 

Granny remains in a critical condition, alternately unconscious and agitatedly confused. She’s stopped eating and drinking. During her brief lucid intervals she tells you and anyone else who will listen that she wants to go home. You know Granny is suffering and that this isn’t what she would want. Granny languishes in hospital and dies a week later. The end is mercifully peaceful, though. You and her entire loving family are by her side as Granny slips quietly away. 

The Last Act, Death Scene: Take 3 

You and the rest of your family are in the Medical Admissions Unit of the local hospital, gathered around Granny’s hospital bed. She’s dying. At ninety-two, she’s had a good innings, though. Her health has been declining for several years, which has been hard for Granny and you all because she was always so active. It’s her failing heart. She gets breathless on minimal exertion these days and has become housebound. She can’t manage her stairs and sleeps on a sofa bed in the lounge. Although Granny knows deep down that her time may be short, she finds it hard to accept. She hasn’t discussed her situation with anyone. It would be too upsetting all round. 

When Granny goes down with pneumonia, a doctor who does not know Granny prescribes her antibiotics. Her condition worsens. By Saturday, she is gasping for breath and can hardly speak. Granny is taken to hospital. After a battery of blood tests, a chest X-ray and a CT scan, the diagnosis of pneumonia is confirmed. Granny receives intravenous fluids and more antibiotics. She becomes confused and doesn’t recognise any of her visitors, including you. You and other family members ask to speak to a doctor. 

The house officer tells you that Granny is very ill but that she’s in the right place and they’re doing everything they can to treat her. Granny remains in a critical condition, alternately unconscious and agitatedly confused. She’s stopped eating and drinking. During her brief lucid intervals she tells you and anyone else who will listen that she wants to go home. 

You are with Granny a few days later. The rest of the family will be along later. Granny’s been asleep the whole time you’ve been visiting, her breathing irregular and raspy. She becomes suddenly silent. Her chest is not moving. You stare at her for a few seconds. The terrible truth strikes you like a bolt of lightning. Screaming at the top of your voice, you race down to the nursing station. ‘Granny’s not breathing! Granny’s not breathing!’ 

Pandemonium erupts. Three nurses race towards Granny’s bed, one of them pushing the resuscitation trolley and defibrillator. A squad of doctors charge down the ward soon afterwards. Horrified, you stare spellbound as Granny’s nightie is torn away to reveal her shrunken, naked breasts. One of the nurses starts performing external chest compressions. You hear the snap as at least one of her ribs breaks under the strain. One of the doctors attaches the defibrillator gel pads while another sucks out vomit from the back of Granny’s throat. The sight is overwhelmingly sickening, but you cannot tear your eyes away. One of the nurses tries to guide you away, but you’re not budging. You can’t move. You are almost literally petrified. 

The scene is noisy. It’s chaotic. It’s frightening. It’s traumatising for you, and for Granny. It’s undignified. It’s the opposite of the calm, peaceful, painless way to go that you imagine a good death to be. More to the point, it’s pointless, you realise. 

Fifteen minutes later it’s all over. Granny is still dead.

I’ve described those three takes to set the scene for the rest of this post. Before continuing, I suggest you spend a few minutes in reflection mode. Which of those scenes would make the director’s cut from Granny’s perspective? From your perspective? What are the important factors that influence which of the takes plays out in real life? 

Of course, I’ve omitted Take 4 in which Granny gets better and goes home again. This is highly improbable given the context I described, although not impossible. How does this possible outcome, however unlikely, colour your judgement of how best to approach Granny’s clinical management? 

Real Life versus TV Medical Dramas

Why don’t hospitals resuscitate everyone who has a cardiac arrest? There’s surely nothing to lose. Nobody should be written off. It’s a human right.

These are all reasonable points. If you’ve watched enough medical dramas, you’ll know exactly how cardiac arrest works. A patient suddenly collapses. Alarms start ringing. Ruggedly handsome doctors and pretty nurses (stereotypically male and female, respectively) sprint down the ward. Someone shouts, “Clear!” A defibrillator is fired. The patient jolts dramatically into the air as a thousand volts or more of electricity course through their chest, and coughs once or twice. The ECG trace, which had hitherto been flatlining, springs back to life with a reassuring ‘beep, beep’ sound. By the next episode, the patient is back at work regaling their colleagues about their near-death experience.

On the television, CPR either works, with a very good chance of the patient bouncing back to a normal life, or it doesn’t. There’s hardly ever any vomit, blood or shit about the place. No broken ribs. No shouting and certainly nothing chaotic. The whole performance is expertly choreographed. Poetry in motion. Real life is somewhat less cinematic with an outcome that is a whole lot less positive. And it’s far, far messier.

Although people feel familiar with cardiac arrest resuscitation, CPR is one of the most misunderstood areas of modern medicine. DNACPR orders are even more misunderstood and often provoke strong reactions. They touch on something people find uncomfortable and don’t like to think about. None of us is immortal. We are all going to die. Despite all its remarkable advances, modern medicine cannot prevent this.

It’s a grim reality, but refusing to acknowledge and accept that simple truth hampers good decision-making around ensuring that somebody’s death, if it cannot be prevented, is as good, as peaceful and as dignified as it can be. That’s good decision-making by doctors but also, crucially, by patients and their families, too.

Success rates for CPR

The return of spontaneous circulation (ROSC, or, to put it simply, the patient’s heart starts beating again) is clearly the goal of CPR. However, the success rate varies enormously depending on why the heart stopped in the first place, where cardiac arrest occurs, how quickly resuscitation begins, the patient’s age and underlying health, and a dozen other factors. There is a key difference between a person dying because their heart has suddenly thrown a wobbler, on the one hand, and a person’s heart throwing in the towel because that person is dying, on the other. For some patients, CPR offers a genuine chance of survival with a good outcome. For others, it offers virtually none. And an outcome worse than death is always on the cards.

As we saw in a previous post, CPR is a violent physical assault on a person. It’s messy. It’s more than distressing to witness as a loved one. It’s often distressing as a healthcare provider, too. And it’s a million miles away from the quiet, peaceful, dignified death that finally comes to us in our own bed at home that we all envisage, if we are forced to contemplate our own mortality. CPR is certainly not a medical intervention that should ever be undertaken lightly.

To determine which patients would benefit from a DNACPR order rather than from the performance of CPR on their dead bodies, we need to think about the different types of people who have a cardiac arrest (we could also say the different types of people who die), why they have had their cardiac arrest (why they have died) and what are the possible outcomes of CPR (there are more than two).

Who is more likely to benefit from CPR?

·         An otherwise reasonably healthy person who suffers a sudden heart rhythm disturbance (VF or pulseless VT) from a heart attack or a cardiomyopathy (often undiagnosed, especially in young people) and drops down dead.

·         A patient who develops a reversible complication during surgery, eg bleeding.

·         An otherwise reasonably healthy person who has a cardiac arrest precipitated by a potentially reversible cause, eg pneumonia, major trauma, tension pneumothorax in an asthmatic, acute intoxication by drugs, drowning in the canal.

A problem arises if we assume that everyone falls into one of these categories. They don’t.

Who is unlikely to benefit from CPR?

·         A frail person with advanced dementia and poor mobility living in a nursing home.

·         A frail person with all their faculties living in their own home.

·         A person with a poor exercise tolerance because of severe chronic heart failure, chronic respiratory disease, a progressive, degenerative neuromuscular disease, or any other debilitating comorbidity.

·         A person with advanced liver or kidney disease.

·         A frail person who develops a life-threatening acute problem, eg pneumonia, heart attack, sepsis, stroke, major trauma.

·         A person debilitated by advanced (incurable) metastatic (Stage 4) cancer.

There are dozens of other examples I could give. The word ‘frailty’ does a lot of heavy lifting in some of the examples given above. It’s defined medically as a loss of physiological reserve and a decline in function across multiple organ systems. It leads to a heightened physical vulnerability,  meaning that adverse events (an infection, broken leg, etc)  that would be relatively trivial under normal circumstances become life-threatening in a frail individual. Although not an inevitable consequence of ageing, there is a good correlation between youth and physiological reserve. After all, how many superfit 90-year-olds do you know who can beat an unfit 20-year-old in the 1500 metres?

What all these conditions have in common is that they describe a person approaching the end of their natural lifespan. Medicine has yet to find an effective treatment for that particular health condition, which we will all develop in due course. When a person’s heart stops in such circumstances, it usually isn’t a random isolated event that can be treated in isolation. It’s more often the culmination of multiple body systems failing. CPR in this context is trying to reverse the irreversible.

The uncomfortable truth is that there are patients for whom CPR has virtually no realistic chance of restoring meaningful life.

Possible outcomes after CPR

·         Resuscitation is successful. The person is discharged from hospital and returns to their normal life.

·         Resuscitation is successful, that is to say, the cardiac arrest victim’s heart starts beating again. However, it’s a pyrrhic victory. Their condition rapidly deteriorates immediately afterwards, and a decision is made that any further resuscitation attempts would be futile. A DNACPR form is signed. I would say this was the second most common outcome after a cardiac arrest on one of the general hospital wards that I attended.

·         Resuscitation is successful, but the patient remains very poorly. Despite continued active medical management, they die in hospital days or weeks later. Some of them meet the same fate despite being admitted to the ICU and put on a ventilator.

·         Resuscitation is successful, but the patient sustains severe irreversible brain damage from oxygen deprivation during the period their heart was stopped. They survive with significant mental and/or physical disability and therefore do not return to a normal life. Some never regain consciousness.

·         Resuscitation is unsuccessful. Game over. The patient and their relatives have not experienced a calm, peaceful, dignified death.

In my view, therefore, it isn’t just a case of saying that everyone is entitled to their shot at CPR because there’s nothing to lose. There’s much to lose, which is why responsible clinicians think not only about whether CPR can restart the heart, but whether it can achieve an outcome the patient (and their family) would actually value.

What is a DNACPR?

DNACPR stands for ‘Do Not Attempt Cardiopulmonary Resuscitation.’

Notice the wording. It does not say: ‘Do not treat.’ ‘Do not care.’ ‘Do not comfort.’ ‘Do not help.’ It says one thing and one thing only: If the patient’s heart stops or they stop breathing because they are dying, do not perform CPR. That’s it. A DNACPR decision has no validity, no impact on a patient’s care, until and unless they are dead. Up until that point, a patient with a signed DNACPR order can be admitted to hospital and receive oxygen, fluids, and antibiotics. They can undergo surgery, chemotherapy or dialysis. Whatever. They can even be admitted to the ICU and put on a ventilator. I know because I admitted many such patients myself.

I would like to deal with two aspects of the clinical care of hospital patients that are often confused with DNACPR decisions. They are ‘Defining A Ceiling of Care’ and ‘Treatment Withdrawal’.

Ceiling of care

This is an entirely separate issue from a patient’s resuscitation status should they go on to have a cardiac arrest. A ceiling of care defines the extent of treatment: the medical interventions deemed appropriate and those deemed inappropriate because the likelihood of benefit is far outweighed by the harm. For one hospital patient with pneumonia, the ceiling might include intravenous fluids and antibiotics, facemask oxygen, chest physiotherapy, and nebulised bronchodilator therapy, but not ICU admission or mechanical ventilation. Another hospital patient with pneumonia might not have a ceiling of care, and every intervention is available to them. It might come as a surprise that such a patient might still have a DNACPR order signed.

A third hospital patient with pneumonia might not be actively managed at all and receive end-of-life care, focused entirely on symptom control and their comfort, every effort being made to facilitate a good death. All these patients have a DNACPR form signed as a matter of course.

The crucial point is that these decisions are individual. They’re based on the patient’s underlying acute diagnosis, their chronic health, their frailty, any comorbidities they may have, their prognosis, and likely outcomes. Patients and their families should be involved in these decisions, although they should not make them. They are personally involved and are not the experts. These decisions are made by the medical and nursing staff.

Withdrawal of Treatment

Imagine a critically ill patient in a hospital who has been receiving treatment for an acute medical condition for some time. It could be hours, days or weeks. Depending on their defined ceiling of care, they may be on a general ward or in the ICU on a mechanical ventilator. Despite everything, it becomes clear that recovery is no longer possible. The medical treatment is serving only to prolong the dying process. At that point, the medical team may discuss withdrawing treatment that is no longer providing benefit. Such discussions naturally involve the patient, if they are conscious and have mental capacity. They will generally involve close family members as well.

If it is agreed that withdrawing treatment is the best option, the patient is transferred to an end-of-life care pathway, and a DNACPR form is signed if one hasn’t already been.

Withdrawing a treatment and never starting it in the first place are ethically very similar. If a treatment is unlikely to benefit a patient, doctors are not obliged to provide it simply because it exists.

Okay. I hear you. The issues surrounding a patient’s resuscitation status are more complicated than I thought. But how do doctors decide if a DNACPR order is appropriate or not?

And before answering that, there is the pithy question: why should it be only the doctors who decide? Surely, it’s the patient’s human right to have the final say. Or their families.

Let’s tackle that second question head-on. Why can’t a patient demand CPR, no matter how futile their doctors believe it would be? Under UK law, any patient who has mental capacity can refuse any medical or surgical intervention, or any drug treatment, if they so wish. They don’t have to give a good reason. Or any reason. Provided they fully understand the implications of refusing the treatment advised, they are free to act as they wish. Doctors may not overrule them, no matter how unwise they think the decision may be. Nor can family members!

However, no patient may demand a surgical or medical intervention, or a drug treatment, that their doctors think is not indicated or unlikely to be beneficial. You can’t demand surgery because you think your normal appendix needs to be removed. Neither can you demand surgery for your perforated bowel if your surgeon and anaesthetist are convinced you will not survive. You can’t demand potentially life-saving chemotherapy for your Stage 4 cancer diagnosis if your doctor (or, more likely, NICE) thinks it is not cost-effective. And you can’t demand CPR. CPR is not special in this regard.

Of course, patients should be involved in the decision-making process. It is absolutely worth finding out that the patient does not want CPR. It’s not that uncommon, particularly as people become older and frailer with this and that thing wrong with them. Many, though certainly not all, elderly people recognise their lives are coming to their inevitable conclusion. They have accepted their own mortality and are as ready as they can be for when the time comes. It’s well worth asking the question!

Families should also be involved when a patient’s resuscitation status is being considered (with the patient’s explicit consent, of course). If a DNACPR decision is made, the full reasoning behind it should be explained, and the patient/family members should be given ample opportunity to ask questions. I invariably found that, if you do this, patients and their families accept the final decision, even if reluctantly.

DNACPR orders shouldn’t be seen as a threat. When the process of signing them is done well, they are an opportunity to explain, in open and honest terms, to a patient and their family, what is wrong with them, what the realistic treatment options are, and what medicine can and cannot achieve for them. It’s about using the D word – sensitively and sympathetically, when appropriate. It’s about reassuring the patient that the medical team is doing everything they possibly can to get the patient better, but that if Plan A fails, Plan B will ensure their death is as comfortable, peaceful and dignified as possible.

Final thoughts

CPR is one of medicine’s success stories. It has saved countless lives and continues to do so every day. But it is neither universally effective nor universally appropriate. A DNACPR decision is not about denying care, writing someone off, or deciding their life has less value. It is about recognising that some treatments help in some situations and harm in others. A quiet, peaceful, dignified death is as much a success story as effective CPR.