who should decide?
It is astonishing that the period of time after which a person’s heart stops often receives more attention than countless more important moments leading up to that instant of stillness. Yet it happens again in an article in this week’s Science Times. “The Last Word on the Last Breath” http://www.nytimes.com/2006/10/10/health/10dnr.html attempts to shed light on whether or not doctors should try to restart a stopped heart. Instead it repeats the mistaken view that this decision belongs with MDs rather than patients. It also places the focus in the wrong place – away from what to do while a person is still alive.
The article’s first mistake is in the headline. The last breath, for a person whose heart has stopped, has already come and gone. The question is whether restarting a person’s heart at that point is compassionate or abusive. It’s not an abstract concern: CPR, which has some efficacy when performed on an otherwise healthy person experiencing a heart attack, is minimally effective when performed on a terminally ill person whose heartbeat is completely arrested.
The article frames the dilemma as a power struggle. Who decides whether CPR is welcome or wanted – the doctor, the patient, the patient’s family? State laws conflict, the article says, but actually the answer ought to be plain. The life belongs to the patient, no one else. Of course concerns arise when the patient’s views are not clearly known, but that raises the real underlying issue: A person dying slowly has many opportunities to weigh the options, to become informed, and to express his or her wishes in documents that guide doctors and protect families from having to make wrenching choices in a moment of crisis.
If you tell a dying cancer patient that he will receive all appropriate care while he is alive, he may thank you. If you tell him that he can choose to receive CPR if his heart stops – which may break his ribs, require forced intubation, lead to countless needle jabs into his groin in order to obtain blood diagnostic information from vessels gone flaccid from the absence of blood pressure – he will say no thank you. He’ll especially make that choice if you inform him that CPR (unlike TV shows where it succeeds 67 percent of the time) enables hospital patients to recover as little as two percent of the time, with half restored only to a vegetative state.
The Times story leaves a clear impression that doctors are best equipped to make CPR decisions. At least that is an improvement over the end-of-life care report from the President’s Commission on Bioethics http://www.bioethics.gov/topics/end_of_life_index.html which felt judges ought to make these calls (a la Terri Schiavo). Nonetheless, doctors’ role should be circumscribed. As the experts, both in care and in assessing a person’s prognosis, doctors have a responsibility to raise the difficult issues – in advance, when the patient can competently consider. Doctors need to educate patients on the difference between caring for a living person and trying to revive a dead one. They need to teach patients what the CPR recovery rate actually is. And then they need to follow orders.
By the way, it wouldn’t hurt if states enacted laws protecting doctors from lawsuits for following a patient’s wishes over family members’ protests. By the way, too, there are countless caregiving opportunities that arise before the patient’s heart stops. If families and doctors set their sights on maximizing the quality of those moments, they might do a better job of accepting the inevitable when it finally arrives.