Michael Gordon MD, MSc, FRCPC is a geriatrician working at Baycrest Health Science System. He is medical program director of the palliative care program, co-head of the clinical ethics program and a professor of Medicine at the University of Toronto. He is the author of Late Stage Dementia, Promoting Compassion, Comfort and Care; Moments that Matter: Cases in Ethical Eldercare and Brooklyn Beginnings: A Geriatrician's Odyssey. For more information see drmichaelgordon.com
On March 4, 2013, the Associated Press reported the death from an apparent cardiac arrest of Lorraine Bayless, an 87 year old resident of Glenwood Gardens, a Bakersfield California independent living home in. The event prompted wide media coverage and public responses because of apparent reluctance for a staff member to start CPR. The comments range from outrage over the apparent abrogation of a responsibility to “save a life” to more sanguine and clinically based responses from those involved in elder care. The question remains, “how much technology should be used in potentially life-ending events when benefits may be much muted and not necessarily result in a future life comparable to that which existed before the event.”
Since my early days in medicine I have always had an interest in the CPR process. When I finished medical school in Dundee Scotland in 1966, CPR was hardly on the agenda as an end-of-life undertaking even in Dundee’s teaching hospitals. I witnessed my first CPR attempt as a young medical student spending a summer at Brooklyn’s Beth-El Hospital (later to be renamed Brookdale Hospital) in New York. One day while doing rounds with the senior medical resident, a patient with severe heart disease, who was receiving oxygen via an oxygen tent (a system used in those days to provide an oxygen rich atmosphere that required no effort or discomfort on the part of the patient and often resulted in patients not being as carefully examined as everyone was “afraid” to open the “tent” lest the oxygen leak out) suddenly turned blue, and by the time we pulled the flaps of the tent away, it was clear that he had “arrested”. This was prior to the advent of readily available closed-chest CPR; therefore the “team” arrived, opened his chest with a “thoracotomy” incision and applied open-chest cardiac massage. Blood was everywhere. The “team” physicians called out instructions to the nurses to continue providing oxygen through an Ambu Bag. After half an hour of effort he was pronounced dead. It was one of the most dramatic events I had witnessed during my early medical education days.
It was many years later after becoming involved in geriatric medicine that I began to seriously question this dramatic undertaking which had been adopted as the “norm” in all the general hospitals in which I had trained was really suitable for most of my very elderly patients with multiple diseases. I witnessed a few such CPR attempts in the last general hospital in which I complete internal medicine training and wondered if rather than providing emergency care we were not committing an assault on this dying woman, who was ravaged my multiple serious diseases and her attempt at “dying” was being interrupted by a technological “marvel” that was completely inappropriate for her. This was before the advent of the concept of an advanced directive, the first one of which was a DNR order. Since most of the staff knew which very elderly, frail patients would not respond to CPR there was a quasi-subterranean silent agreement about what became known as “slow codes” whereby staff “went through the motions” of CPR it was without the rigor required for success. The patient could be pronounced dead and the chart would say, “CPR attempted but failed.” Ultimately the DNR protocol was introduced and accepted by the legal community as valid and acceptable to refuse even potentially life-saving treatment. A lot of time and experience has passed since those early days. Now, especially in the long-term care system, the goal should be one of early communication and documentation as to wishes for CPR with a full explanation of the dismal outcomes frail elders living in long term care facilities and the understanding that in many ways the process is akin to an “assault”.
Nursing and retirement homes catering to older individuals should have clear policies that are communicated to residents, patients and their families as to what can and cannot, will or will not be done in the event of a sudden loss of vital signs when deemed to be due to a cardiac arrest. Wishes for DNR status should be documented so that everyone in a position to make a decision about initiating CPR knows about the DNR request. Of particular importance when it comes to such discussions and decision-making, the evidence is quite compelling that in the very elderly; especially those with multiple pathologies and experiencing dementia as part of their collection of chronic medical conditions, the results of CPR are particularly dismal. Moreover, the effect on the person receiving almost as a last rite of modern North American medicine is in many ways quite brutal in its impact. The evidence indicates strongly that in the absence of a DNR order, no attempts at CPR should be taken unless the event is witnessed and was not expected by nature of some acute underlying illness such as a serious infection or serious heart ailment. Only then should an attempt at defining the event with the portable monitors so readily available should be undertaken and if deemed suitable DC defibrillation will occur while CPR is performed until EMS arrives and takes over. If the communication and proper protocols are in place such an undertaking will occur rarely and hopefully only in those who have any semblance of a positive outcome. One should not have to pass through the gates of modern technology to leave this world peacefully and in a humane fashion.
