Do not resuscitate – why death needs to have heart

So: Addenbrooke’s hospital are being sued for allegedly illegally using a ‘do not resuscitate order’ on a patient. The patient had allegedly expressed that she wished to be resuscitated, but apparantly the order was written anyway.

Meantime, we have Iona Heath writing in the BMJ about how CPR “amounts to yet another scenario within contemporary medicine where the chance of benefit for the few creates procedures that risk the peace and dignity of the many. I only hope that by the time I am old and sick I will have to actively opt in for CPR, rather than my consent being assumed unless I have opted out.”

There is something troubling me, and it is to do with the perceived power of doctors over life and death. CPR is not a great treatment, and it does harm. I don’t just mean fractured ribs or blood loss or bruises, I mean what the meaning of death is.

Doctors who have looked after patients in the last stages of their life hope that a good death can follow. Sometimes family members can understandably panic when life is ebbing, especially if there seems pain or distress. The problem that ambulance crews have is that they work to a protocol where they must resuscite any dying patient; and what should be a time of comfort and togetherness becomes a medical battleground. It is hard for a doctor to arrive and to call time and stop a ‘treatment’ that should never have been started. We seem to regard death as something that should always be obstructed. Death is seen as a failure of medicine rather than an inevitability of life. This is dangerous.

When we start to instruct doctors to offer ineffective and harmful treatments, such as CPR when it has little or no chance of  a good outcome, we are opening medical professional behaviour to the vagaries of consumerism. We should always perform CPR if there is a good change of benefit – even a small chance of benefit. But if doctors are to be told to prolong suffering, or contaminate a good death with our invasion and orders, medicine becomes actively harmful. I have seen patients asked if they want CPR even when, through their combination of several serious and lifelimiting illnesses, there would be marginal if any chance of success, and much of harm. Is this fair? Read this review in the Journal of Medical Ethics. Or there is more evidence about the effectiveness of CPR here. If we are serious about ‘dying well‘ we have to accept the futility of much of medicine, and instead allow care – decent, compassionate, ethical – to shine through.

3 Responses to “Do not resuscitate – why death needs to have heart”

  1. Dee Speers August 27, 2011 at 5:58 pm #

    I agree with all you say and basically when the time has come (and it will) one hopes for a peaceful exit from this mortal coil. A good life followed by a good death must be the aim. I suppose whats worrying me is just like the differences another blog pointed out aka “Nothing left to resuitate Doc” and “do everything that you can”…..there are huge differences in personalities involved too. Like your comment “There is something troubling me, and it is to do with the perceived power of doctors over life and death.” and maybe having been failed and saved by NHS, I have both a jaundiced and eternally grateful view of the standard of care I have received.

    One senior doctor shunned his diligent pathologists report and relied instead on a discriminatory opinion that !”as a middle aged white woman who lived in a village and didn’t travel very much, she couldn’t possibly have renal TB and if she was part of the Asian population locally I would have tested her!” I subsequently collapsed and spent 6 months in hospital with tb/meningitis and almost died twice. But wonderful dedicated care saw me recover. I suppose the feelings around system failures witnessed at Mid Staffordshire and “doctors prescribing water” at Ipswich Trust, whilst the CEO accepts “public sector director of the year” award and feels “humbled” 5 days after CQC slam his Trust have added to the jaundiced side!

    Basicailly, as members of the public we need to know that the systems we pay for to protect and support us are working in our interests…we cant ignore there were doctors like Harold Shipman and Clifford Ayling and whilst there are many doctors who are completely opposed to all Shipman and Ayling did, we cant ignore that the recommendations made in the Shipman case are still just recommendations and if Shipman was alive he would be entitled to be an expert witness for investigations. We have areas of the system which are fundamentally flawed and like all relationships if we don’t have trust we have nothing but hope and self preservation. Sadly front line staff carry a very heavy burden!

  2. Margaret McCartney
    margaretmccartney August 27, 2011 at 6:57 pm #

    Jonny has written well on this here:

    Doctors and patients should be on the same side. Personal relationships and trust are the keystones of good medicine. Doctors will make mistakes, medicine can never be perfect. What can make it better is honesty, even if that honesty is hard.

  3. steve August 29, 2011 at 5:03 pm #

    Please let’s leave Shipman out of all this. He was a mass murderer who happened to be a doctor and the recommendations made following his case were little more than a hostile attack on an entire profession which almost certainly would not have caught Shipman!