Heroic Measures -- Or Not

"CPR was invented to restart the hearts of otherwise healthy people who are having heart attacks. The people who developed it -- I don't think they could ever have envisioned that CPR would be the norm and the default treatment for anyone who is essentially dying."
"Patients kind of get put on an automatic default care pathway, where the assumption is, because we have a lot of technology we should use, we can use it and so we will use it. For a good proportion of patients, just because we can do it doesn't mean it's the kind of care we would necessarily want."
"Where we let patients and families down is that we just don't spare the time to really talk with them and understand what their wishes are and what their values are, just to make sure that we're honouring what they want."
"To me, it speaks to human optimism. I just think we are hardwired to be overly optimistic. (Doctors) went into medical school to save people's lives. There may be some reluctance to accept that patients are actually going to die."
Dr. John You, associate professor of internal medicine, McMaster University, Hamilton; member of the Canadian Researchers at the End of Life Network

Dr. You bemoans the fact that elderly Canadians are dying hooked up to machines, tubes and monitors simply because doctors haven't taken the time to discuss with them what level of care they would or would not prefer to receive at what appears to be their end of life process. He and some of his colleagues have produced a new guide for physicians to aid them on advancing end-of-life care planning.

The purpose of the guide is to give confidence to doctors who might prefer to evade the kind of extremely confrontational experience that is certain to ensue in mutual distress when they inform a deathly ill elderly patient and the patient's family members that it is the doctor's considered professional opinion that there is little use in relying on technology to extend a life no longer worth living given the extent of bodily breakdown and the imminence of death.

Physicians are given guidelines by which they may identify those patients who present at high risk of imminent death. And with those patients it is incumbent upon the attending physician to engage in full, frank discussions about life-prolonging interventions, including CPR. Which, the guide stresses, for the sickest patients in intensive care units, bears little resemblance to the sanitized outcomes seen on television medical dramas.

"Most will have substantially diminished function", the guide warns. "They will end up reliant on others to perform the most mundane of ordinary life functions. They will ultimately be discharged to a hospice or a nursing home." Under those conditions of what value is life to them? The problem is that doctors and other health-care workers in a hospital "infrequently engage patients and families in such conversations".

In a recent study Dr. You's research team interviewed elderly patients at high risk of dying within a short period of time. "What we found was striking", Dr. You said. Roughly half of patients had discussed their care wishes around end-of-life situations with a member of the health-care team and a minority would opt for CPR. The "code status" on their bed charts, however were recorded as "full code" which meant that CPR along with any other possible intervention would be used to keep them alive.

"That, to me, shouldn't really be happening. My hope is that by having (end-of-life care) conversations we can really provide the care that patients and families want, and not subject them to things they wouldn't have wanted. Everyone tries to see things in the best possible light. People are trying to be hopeful for the best possible outcome. To acknowledge death and dying, you sometimes feel like you're painting a negative picture But the reality is, we're all going to die one day."

Which, needless to say, is true. On the other hand, if an ill patient seeking medical intervention to prolong life really has every intention of continuing to eke out the last bit of opportunity for continued life possible, who has the right to deny them that privilege? And who can foresee how a very ill elderly person would react to attending physicians encouraging them to surrender life when to do so is the furthest thing from their minds?

Informing them of the futility of intervention might just nudge them toward a direction they had no intention of heading in but do because they now feel they have an obligation to put out the lights on a life they feel hasn't been completely lived to its full potential. That to do so is expected of them, as a responsible elderly individual who doesn't want to cause any more fuss about his needs.

Most people, elderly or not, who are in huge pain and no longer have a wish to continue living, express that sentiment. That is when extraordinary life-extending measures could rationally be withdrawn. Those whose bodies are worn, but who are nonetheless imbued with a spirit that spurs them to continue enjoying life in whatever measure they can, should be encouraged to do so.

It is a form of arrogance of the medical profession in this regard to believe that patients would be happy to accede to suggestions by doctors that it's time to cash in their chips. If the patient is that extremely ill and hovering on the cusp of death, then the closest relatives, presumably, make that critical call, to withhold heroic measures.

From any perspective, this is a hard call to make. It is one that differs from individual to individual, circumstance to circumstance, and there is no generalized one-size-fits-all response.