- Email: [email protected]
‘Do not attempt cardiopulmonary resuscitation’ or ‘allowing natural death’? The time for resuscitation community to review its boundaries and its terminology
Resuscitation 85 (2014) 1644–1645
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
‘Do not attempt cardiopulmonary resuscitation’ or ‘allowing natural death’? The time for resuscitation community to review its boundaries and its terminology
The term “do not attempt cardiopulmonary resuscitation” (DNACPR) replaced in the United Kingdom (UK) the older term “do not attempt resuscitation” (DNAR). The terminology changed, at least in the UK, due to misconception of what DNAR really is, as resuscitation is not necessarily only cardiopulmonary resuscitation (CPR). As a result several articles which appeared in the literature defined that DNACPR clearly suggests that CPR should not be started in case of cardiac arrest, but this does not mean the withholding of any other treatment.1 Despite the many legislative variations around the world regarding the possibility of withholding a potentially beneficial procedure such as CPR, many different countries have embraced different realities. There are countries that allow DNACPR and countries where withholding CPR is a criminal offense.2 For these countries that DNACPR is an option, the decision may lay with the team of healthcare providers or with the patient’s wishes (advanced directives).3,4 In this issue of Resuscitation an article attempts to systematically review the available studies to elucidate ways of improving the use of DNACPR.5 Despite the inherent limitations, cultural or religious, of addressing such an issue the authors of the study did an excellent job in collecting and addressing the available evidence. It is noteworthy that even if the authors aimed at a meta-analysis, the studies were so heterogeneous that this aim was not achieved. Moreover, the included studies were mainly from USA, UK and Australia and the quality of the included studies was strong only in two of the 37 included studies with only 8 of them being randomized controlled trials. This possibly reflects the inability of performing strong evidence in a sensitive issue such as withholding CPR in patients in countries where the culture and legislation do not accept DNACPR orders or patient advanced directives; so in these countries CPR should be offered to any patient who develops cardiac arrest, irrespective of the quality of life or the possible outcome of CPR. As with all End of Life (EOL) Decisions, DNACPR is one of the alternatives the healthcare personnel need to bear in mind when dealing with a dying patient.6 CPR has met its glory and now it is time to consider its limits7 and within this theoretical frame this study adds a lot to the current literature. Despite the fact that we often feel that only meta analyses offer insight, other ways of presenting and synthesizing data have been http://dx.doi.org/10.1016/j.resuscitation.2014.09.012 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
acceptable in disciplines such as medical education.8 The comparison between ethical decisions and medical education is not by accident as both are culturally and societally bounded. This study5 elegantly synthesized the available evidence in a qualitative manner. The problems though with EOL decisions is the fact that many issues and many stakeholders need to be informed and each country embraces a unique perception of what resuscitation really is. The real dilemma is that we have not achieved immortality and we are far from stating that CPR will result in meaningful survival for all of the patients it is employed.7 The paper in this issue tackles with sensitive issues with dignity, but the aim of this editorial is not only to praise a well performed study and a well written article but rather to open a debate on terminology currently used in resuscitation. The author of the present editorial previously reported that the term cardiopulmonary resuscitation is outdated and does not reflect the physiology of resuscitation9 and this editorial will address the issue of the terminology of DNACPR. The main issue in many countries, including Greece,10 is the fact that the term DNACPR has a negation, namely the negation to provide CPR. From a legislative point of view this can be an obstacle in many countries where religion or social cohesion is different from countries such as USA, UK and Australia. The debate of whether the term DNACPR should be replaced with a more positive term is not new. It is beyond the aim of this short commentary to address the issues of healthcare paternalism that are obvious in the UK DNACPR decision making, or to address the legislation problems that have recently been made evident in the USA regarding DNAR/DNR.3 The review in this issue addresses core issues of EOL decisions, associating these with clarity about the benefits of CPR, structured communication between multidisciplinary healthcare teams of professionals and continuous education with the aim of reducing harm for the patient. It might be beneficial for the Resuscitation Community to review and openly discuss the terms DNACPR or DNAR/DNR in the USA, with a different term which was introduced almost a decade ago. The proposed term is “Allow Natural Death” (AND).11 So far the terminology (DNACPR/DNAR/DNR) the resuscitation community has used, implied that something is not going to be done and this can lead to the misconception that we are withholding treatment; this
Editorial / Resuscitation 85 (2014) 1644–1645
may result in reluctance in part of the family or the patient to accept that the outcome, even if CPR is initiated is going to be very poor, if at all successful. Allow natural death implies that all measures will be taken to provide comfort for the patient, explaining that CPR is not likely to restore circulation and improve meaningful survival. What previous research has documented12 and this paper has also clearly shown is that a collaborative model where all stakeholders, including physicians, nurses, the patient and the relatives need to be implemented. Often family members and patients have fear of the negation experiencing both anxiety and expressing conflict with the treating team. Individuals tend to respond differently in stressful environments and it is very possible that the fact that the poor implementation of the DNACPR order is associated with the fact that the order may appear threatening leading families and patients with a perception of cruelty.11 Previous research has clearly associated negative words with strong emotional reactions, especially in stressful environments or situations. In the paradigm where the patient or the family is involved in the EOL decision making process, this may well account for the fact that so many futile resuscitation attempts are being undertaken world-wide. What we may need to consider is to change the order from DNACPR to AND, explaining clearly the process that all measures will be taken to ensure comfort in a dying patient, and reassure that treatment will be continued, but in case of cardiac arrest, CPR may restore cardiac function, but it will simply prolong a fatal disease, reducing the quality of life. Possibly the rewording of a negative order or a negative advanced directive may lead to legislative changes throughout Europe and probably the rest of the world. With the new terminology the three pylons of ethical healthcare provision, namely autonomy (the principal that a patient can accept or refuse treatment), beneficence (where the healthcare professionals provide treatment that will be beneficial for the patient) and non-malevolence will no longer be ambiguous, leading to different legislative interpretations in different countries.2 On the other hand, there are voices that state that this change is premature and maybe dangerous as it robs patients and families of the possibilities to discuss various EOL options.13 This editorial is not aiming at providing a solution. On the contrary, it states that the resuscitation community should clearly and openly discuss its terminology in all areas of resuscitation. The article that appears in this issue gives enough clues as to why we need to refocus our attention to a more proper implementation of EOL decisions that do not necessarily include CPR. All International Resuscitation Organizations need to rethink their terminology starting from the basics and DNACPR may be a good starting point.
1645
1. Conflict of interest statement The author of the present manuscript has no conflict of interest to declare. References 1. Bishop JP, Brothers KB, Perry JE, Ahmad A. Reviving the conversation around CPR/DNR. Am J Bioeth 2010;10:61–7. 2. Baskett PJ, Lim A. The varying ethical attitudes towards resuscitation in Europe. Resuscitation 2004;62:267–73. 3. Schlairet MC, Cohen RW. Allow-natural-death (AND) orders: legal, ethical, and practical considerations. HEC Forum 2013;25:161–71. 4. Bailey FA, Allen RS, Williams BR, et al. Do-not resuscitate orders in the last days of life. J Palliat Med 2012;15:751–9. 5. Field RA, Fritz Z, Baker A, Grove A, Perkins GD. Systematic review of interventions to improve appropriate use and outcomes associated with Do-Not-AttemptCardiopulmonary-Resuscitation Orders. Resuscitation 2014. 6. Whitcomb JJ, Ewing N. A closing word: do not resuscitate versus allow natural death and should we change our approach. Dimens Crit Care Nurs 2012;31:265–6. 7. Bishop JP, Brothers KB, Perry JE, Ahmad A. Finite knowledge/finite power: death panels and the limits of medicine. Am J Bioeth 2010;10:W7–9. 8. Cook DA. Narrowing the focus and broadening horizons: complementary roles for nonsystematic and systematic reviews. Adv Health Sci Educ Theory Pract 2008;13:391–5. 9. Xanthos T, Iacovidou N, Ekmektzoglou KA. From cardiopulmonary to cardiorespiratory resuscitation. Resuscitation 2011;82:1360. 10. Chliara D, Chalkias A, Horopanitis EE, Papadimitriou L, Xanthos T. Attitude of elderly patients towards cardiopulmonary resuscitation in Greece. Geriatr Gerontol Int 2013, http://dx.doi.org/10.1111/ggi.12184 [Epub ahead of print]. 11. Venneman SS, Narnor-Harris P, Perish M, Hamilton M. Allow natural death versus do not resuscitate: three words that can change a life. J Med Ethics 2008;34:2–6. 12. Jezewski MA. Do-not-resuscitate status: conflict and culture brokering in critical care units. Heart Lung 1994;23:458–65. 13. Chen YY, Younger SJ. “Allow natural death” is not equivalent to “do not resuscitate”: a response. J Med Ethics 2008;34:887–8.
Theodoros Xanthos a,b,∗ University of Athens, Medical School, MSc program “Cardiopulmonary Resuscitation”, Greece b Hellenic Society of Cardiopulmonary Resuscitation, Greece a
∗ Correspondence
to: 89 Patision Street, 10434, Athens, Greece. E-mail addresses: [email protected], [email protected]. 11 September 2014 14 September 2014
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
‘Do not attempt cardiopulmonary resuscitation’ or ‘allowing natural death’? The time for resuscitation community to review its boundaries and its terminology
The term “do not attempt cardiopulmonary resuscitation” (DNACPR) replaced in the United Kingdom (UK) the older term “do not attempt resuscitation” (DNAR). The terminology changed, at least in the UK, due to misconception of what DNAR really is, as resuscitation is not necessarily only cardiopulmonary resuscitation (CPR). As a result several articles which appeared in the literature defined that DNACPR clearly suggests that CPR should not be started in case of cardiac arrest, but this does not mean the withholding of any other treatment.1 Despite the many legislative variations around the world regarding the possibility of withholding a potentially beneficial procedure such as CPR, many different countries have embraced different realities. There are countries that allow DNACPR and countries where withholding CPR is a criminal offense.2 For these countries that DNACPR is an option, the decision may lay with the team of healthcare providers or with the patient’s wishes (advanced directives).3,4 In this issue of Resuscitation an article attempts to systematically review the available studies to elucidate ways of improving the use of DNACPR.5 Despite the inherent limitations, cultural or religious, of addressing such an issue the authors of the study did an excellent job in collecting and addressing the available evidence. It is noteworthy that even if the authors aimed at a meta-analysis, the studies were so heterogeneous that this aim was not achieved. Moreover, the included studies were mainly from USA, UK and Australia and the quality of the included studies was strong only in two of the 37 included studies with only 8 of them being randomized controlled trials. This possibly reflects the inability of performing strong evidence in a sensitive issue such as withholding CPR in patients in countries where the culture and legislation do not accept DNACPR orders or patient advanced directives; so in these countries CPR should be offered to any patient who develops cardiac arrest, irrespective of the quality of life or the possible outcome of CPR. As with all End of Life (EOL) Decisions, DNACPR is one of the alternatives the healthcare personnel need to bear in mind when dealing with a dying patient.6 CPR has met its glory and now it is time to consider its limits7 and within this theoretical frame this study adds a lot to the current literature. Despite the fact that we often feel that only meta analyses offer insight, other ways of presenting and synthesizing data have been http://dx.doi.org/10.1016/j.resuscitation.2014.09.012 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
acceptable in disciplines such as medical education.8 The comparison between ethical decisions and medical education is not by accident as both are culturally and societally bounded. This study5 elegantly synthesized the available evidence in a qualitative manner. The problems though with EOL decisions is the fact that many issues and many stakeholders need to be informed and each country embraces a unique perception of what resuscitation really is. The real dilemma is that we have not achieved immortality and we are far from stating that CPR will result in meaningful survival for all of the patients it is employed.7 The paper in this issue tackles with sensitive issues with dignity, but the aim of this editorial is not only to praise a well performed study and a well written article but rather to open a debate on terminology currently used in resuscitation. The author of the present editorial previously reported that the term cardiopulmonary resuscitation is outdated and does not reflect the physiology of resuscitation9 and this editorial will address the issue of the terminology of DNACPR. The main issue in many countries, including Greece,10 is the fact that the term DNACPR has a negation, namely the negation to provide CPR. From a legislative point of view this can be an obstacle in many countries where religion or social cohesion is different from countries such as USA, UK and Australia. The debate of whether the term DNACPR should be replaced with a more positive term is not new. It is beyond the aim of this short commentary to address the issues of healthcare paternalism that are obvious in the UK DNACPR decision making, or to address the legislation problems that have recently been made evident in the USA regarding DNAR/DNR.3 The review in this issue addresses core issues of EOL decisions, associating these with clarity about the benefits of CPR, structured communication between multidisciplinary healthcare teams of professionals and continuous education with the aim of reducing harm for the patient. It might be beneficial for the Resuscitation Community to review and openly discuss the terms DNACPR or DNAR/DNR in the USA, with a different term which was introduced almost a decade ago. The proposed term is “Allow Natural Death” (AND).11 So far the terminology (DNACPR/DNAR/DNR) the resuscitation community has used, implied that something is not going to be done and this can lead to the misconception that we are withholding treatment; this
Editorial / Resuscitation 85 (2014) 1644–1645
may result in reluctance in part of the family or the patient to accept that the outcome, even if CPR is initiated is going to be very poor, if at all successful. Allow natural death implies that all measures will be taken to provide comfort for the patient, explaining that CPR is not likely to restore circulation and improve meaningful survival. What previous research has documented12 and this paper has also clearly shown is that a collaborative model where all stakeholders, including physicians, nurses, the patient and the relatives need to be implemented. Often family members and patients have fear of the negation experiencing both anxiety and expressing conflict with the treating team. Individuals tend to respond differently in stressful environments and it is very possible that the fact that the poor implementation of the DNACPR order is associated with the fact that the order may appear threatening leading families and patients with a perception of cruelty.11 Previous research has clearly associated negative words with strong emotional reactions, especially in stressful environments or situations. In the paradigm where the patient or the family is involved in the EOL decision making process, this may well account for the fact that so many futile resuscitation attempts are being undertaken world-wide. What we may need to consider is to change the order from DNACPR to AND, explaining clearly the process that all measures will be taken to ensure comfort in a dying patient, and reassure that treatment will be continued, but in case of cardiac arrest, CPR may restore cardiac function, but it will simply prolong a fatal disease, reducing the quality of life. Possibly the rewording of a negative order or a negative advanced directive may lead to legislative changes throughout Europe and probably the rest of the world. With the new terminology the three pylons of ethical healthcare provision, namely autonomy (the principal that a patient can accept or refuse treatment), beneficence (where the healthcare professionals provide treatment that will be beneficial for the patient) and non-malevolence will no longer be ambiguous, leading to different legislative interpretations in different countries.2 On the other hand, there are voices that state that this change is premature and maybe dangerous as it robs patients and families of the possibilities to discuss various EOL options.13 This editorial is not aiming at providing a solution. On the contrary, it states that the resuscitation community should clearly and openly discuss its terminology in all areas of resuscitation. The article that appears in this issue gives enough clues as to why we need to refocus our attention to a more proper implementation of EOL decisions that do not necessarily include CPR. All International Resuscitation Organizations need to rethink their terminology starting from the basics and DNACPR may be a good starting point.
1645
1. Conflict of interest statement The author of the present manuscript has no conflict of interest to declare. References 1. Bishop JP, Brothers KB, Perry JE, Ahmad A. Reviving the conversation around CPR/DNR. Am J Bioeth 2010;10:61–7. 2. Baskett PJ, Lim A. The varying ethical attitudes towards resuscitation in Europe. Resuscitation 2004;62:267–73. 3. Schlairet MC, Cohen RW. Allow-natural-death (AND) orders: legal, ethical, and practical considerations. HEC Forum 2013;25:161–71. 4. Bailey FA, Allen RS, Williams BR, et al. Do-not resuscitate orders in the last days of life. J Palliat Med 2012;15:751–9. 5. Field RA, Fritz Z, Baker A, Grove A, Perkins GD. Systematic review of interventions to improve appropriate use and outcomes associated with Do-Not-AttemptCardiopulmonary-Resuscitation Orders. Resuscitation 2014. 6. Whitcomb JJ, Ewing N. A closing word: do not resuscitate versus allow natural death and should we change our approach. Dimens Crit Care Nurs 2012;31:265–6. 7. Bishop JP, Brothers KB, Perry JE, Ahmad A. Finite knowledge/finite power: death panels and the limits of medicine. Am J Bioeth 2010;10:W7–9. 8. Cook DA. Narrowing the focus and broadening horizons: complementary roles for nonsystematic and systematic reviews. Adv Health Sci Educ Theory Pract 2008;13:391–5. 9. Xanthos T, Iacovidou N, Ekmektzoglou KA. From cardiopulmonary to cardiorespiratory resuscitation. Resuscitation 2011;82:1360. 10. Chliara D, Chalkias A, Horopanitis EE, Papadimitriou L, Xanthos T. Attitude of elderly patients towards cardiopulmonary resuscitation in Greece. Geriatr Gerontol Int 2013, http://dx.doi.org/10.1111/ggi.12184 [Epub ahead of print]. 11. Venneman SS, Narnor-Harris P, Perish M, Hamilton M. Allow natural death versus do not resuscitate: three words that can change a life. J Med Ethics 2008;34:2–6. 12. Jezewski MA. Do-not-resuscitate status: conflict and culture brokering in critical care units. Heart Lung 1994;23:458–65. 13. Chen YY, Younger SJ. “Allow natural death” is not equivalent to “do not resuscitate”: a response. J Med Ethics 2008;34:887–8.
Theodoros Xanthos a,b,∗ University of Athens, Medical School, MSc program “Cardiopulmonary Resuscitation”, Greece b Hellenic Society of Cardiopulmonary Resuscitation, Greece a
∗ Correspondence
to: 89 Patision Street, 10434, Athens, Greece. E-mail addresses: [email protected], [email protected]. 11 September 2014 14 September 2014