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Wilkommen to my blog - my name is Karin Purshouse, and I'm a doctor in the UK. If you're looking for ramblings on life as a junior doctor, my attempts to dual-moonlight as a scientist and balancing all that madness with a life, you've come to the right place. I'm currently a doctor/research trainee in oncology after spending a year doing research in the USA. All original content is licensed under a Creative Commons Attribution 4.0 International License.

Wednesday, 25 June 2014

To resuscitate, or do not resuscitate?

I recently had my first full discussion with a family about resuscitation.  I had watched many such discussions happen previously.  Like an actor, I practiced my lines; a few variants of them, in fact, depending on how the conversation might go.  The family had thought about it already.  They did not think resuscitation would be appropriate, and I agreed.  We discussed and agreed a ceiling of care.  Everything was documented, and a DNACPR form completed.  My consultant countersigned the form later that day. 

Not all discussions are like that.  Resuscitation is stressful, whether you do it or not. 

Resuscitation has become a major political issue, with a recent legal ruling putting it into the spotlight once more. This ruling confirmed that it is now a legal duty for doctors to discuss with patients and/or their families before putting a DNACPR form in place.  To confirm, prior to this it was considered best practice, and in all honesty I can't remember any occasions where the family was not consulted.  

Resuscitation is such a thorny issue.  Casualty, ER, Holby City... they are all a little guilty of giving an overly optimistic presentation of resuscitation.  There is a scene in the second Hunger Games film where Peeta Melarck miraculously recovers after a few rounds of breaths and chest compressions.  The hard medical facts are: chest compressions and breaths alone will never revive someone with genuine cardiac arrest (that is to say, if they are, they didn't actually have a cardiac arrest) - they are an important holding measure.  Full CPR means chest compressions, drugs and sometimes electrical shocks.  And it is hard work.  Ribs are often cracked.  Blood needs to be taken.  Shocks can be delivered.  And success rate in terms of survival to discharge is an optimistic 15-20%, and this paper highlights that there are a range of factors that predict the likelihood of success - renal failure, sepsis and previous lifestyle being among those most cited as predicting failure.  Ultimately, with the best will in the world, some patients have multi organ failure that no amount of CPR is going to fix, and certainly not in a way that will result in a positive long term outcome.

Most patients and their families understand this, and I have a lot of respect for the families who engage in this discussion at what is usually a highly emotional and difficult time.  And of course I agree with the recent ruling in terms of what it is trying to achieve - families should be involved.

But the problem is that not all families agree, and some have unrealistic expectations of what CPR can achieve.  Perhaps that is our fault for not fully explaining what is happening medically - but truly I have witnessed this challenge in the face of the most thorough explanations.  What then?  The risk is inappropriate attempts to resuscitate someone in a quite traumatic and aggressive way with no discernible hope of success - and I think that's also something worth fighting against.  Sometimes situations arise quickly, in the middle of the night or family cannot be contacted.  What's the right thing to do legally as well as for the patient?

DNACPR does not mean 'do not treat'.  DNACPR means not doing CPR if the heart stops or they stop breathing.  It does not mean that infections won't be treated, fluids won't be administered and nutrition won't be given.  It is not equivalent to saying you think someone is actively dying.  Equally it is not a one-way street, and can be reviewed if the clinical situation changes.  

If being a doctor has taught me anything, it is that I would want clear information sharing about resuscitation wishes ahead of time between my family and I.  In terms of the here and now, I will try not to shy away from these discussions, and hope that if this recent debate has had one benefit, it is that people think ahead of time what they and their relatives would want.