As patients, we literally surrender our bodies and minds into our doctors’ hands. We could not be more vulnerable. For a clinician to exploit this power in any way at all is monstrous, an affront to decency.
No one is suggesting that any of the medics who, since March last year, signed more than 500 “do not resuscitate” (more accurately, “do not attempt cardiopulmonary resuscitation”) forms without first discussing the matter with the patients or their families had any intention of shortening life. But when you possess the power to save, prolong, shorten or end life – as all doctors, in theory, do – then it is essential for your integrity and professionalism to measure up to your patients’ faith in you. Your motives and values should be irreproachable.
It is this broader context of power dynamics in medicine that makes the new Care Quality Commission (CQC) investigation into decisions during the pandemic on “do not attempt CPR” such uncomfortable reading for both doctors and patients. The report reveals that 119 adult social-care providers felt they had been subjected to blanket “do not attempt CPR” decisions, imposed by GPs upon all their residents, since the start of the pandemic. Hundreds more such decisions were made without any prior discussion with patients or their families – a clear breach of both the law and best practice.
The notion of doctors making lofty life-and-death decisions without deigning first to discuss them with the minions they concern is deeply unnerving. If doctors’ intentions really are benign and uncontentious – based around the harms and benefits of a particular treatment – why would they choose not to share them?
Eleanor Sturge, whose 62-year-old husband died of Covid in the care home where he lived following a stroke, shared with the CQC a letter she received from a GP. It stated that, after examining her husband’s medical notes and using a computer algorithm, the GP had decided: “There is less than 1% chance of resuscitation being successful. For this reason I have signed a ‘do not resuscitate’ order in their nursing notes.”
The notion of doctors making lofty life-and-death decisions without deigning first to discuss them with the minions they concern is deeply unnerving. If doctors’ intentions really are benign and uncontentious – based around the harms and benefits of a particular treatment – why would they choose not to share them? Might those judgments be less about the clinical efficacy of CPR and more about whether the life of a patient with dementia or disability is deemed to be worth living? Are they, in short, playing God: choosing who “deserves” the chance of resuscitation, according to the presumed quality of their life?
The CQC has done a great service in highlighting all these concerns. The only way for the medical profession to address suspicion and mistrust around “do not attempt CPR” is with openness and candour.
It is clear that something went very wrong during the first wave of the pandemic. Careful, sensitive, personalised conversations with patients and families didn’t always happen. We can blame the chaos of an unfolding pandemic – every aspect of the NHS faced exceptional stresses – but the bottom line is we need to do better.
First, we need to explain that CPR means something very specific. It is the term we use for chest compressions and electric shocks to a heart that has stopped beating – and is reserved exclusively for someone who has already suffered a cardiac arrest. In a sense, the patient has already died: we are trying our hardest to resurrect them.
A “do not attempt CPR” order does not mean we make no attempt to prolong a patient’s life. All manner of other treatments may well be appropriate, such as fluids, antibiotics, admission to hospital, or even treatment in an intensive care unit. The only thing ruled out is chest compressions and shocks to the heart.
Like every other medical treatment – from chemotherapy to major surgery, and transplants to antibiotics – CPR has harms as well as benefits. Resuscitation is an ugly, aggressive and often traumatic treatment. Only in around 10% of cases does all the effort reap rewards. It is nothing like what you see on TV. Too often, the heart cannot be restarted and all we achieve is a cacophony of alarms, wires, shocks and needles in place of dignified dying.
Even if the patient’s pulse is restored, there is a risk their cardiac arrest may leave them profoundly brain damaged. During the pandemic, we have also been acutely conscious of the risks of removing patients from their homes – places they know and love – into a hospital environment steeped in Covid. This may save their life, but it may also mean they never see another human face again – only people in masks and machines at their bedside.
I believe that those rushed, overwhelmed doctors who failed to conduct proper “do not attempt CPR” discussions last year never intended to discriminate, ration treatment or deny care on the basis of arbitrary features such as age. I suspect, rather, that they were trying to avoid patients being subjected to undignified and futile attempts at resuscitation. They were trying, clumsily, to minimise harm. One of the defining questions of modern medicine is, after all, whether it is better to facilitate a peaceful death or to administer a heroic but possibly distressing treatment. We can almost always keep going, but should we?
Last year’s failings give us an invaluable opportunity to do things differently in the future. Better training on discussions over treatment should be embedded into medical school from day one. And it’s not just doctors who need to talk openly and clearly with patients and families. We could, as a society, do better. Advance care planning – deciding how aggressively you would like your doctors to intervene on your behalf – could start now, over a cup of tea, with your family. Let your husband or daughter know if you’d ever want to be ventilated or receive CPR. Make sure your wishes are known and communicated. Because, as we all know, you only die once. How much better to do it on your terms.
Rachel Clarke, a palliative care doctor. The article published in The Guardian
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