Spring, 2005
Question: A 64-year-old Portuguese-speaking woman was admitted for dehydration, exhaustion and delirium. She had undergone surgery, chemotherapy and radiotherapy for colon cancer but had developed rapidly progressing metastatic liver disease. On her last oncology visit a decision was made to stop further chemotherapy and enlist hospice for end-of-life care.
She had immigrated to the United States 20 years ago. She had worked in the domestic service of a local hotel, lived alone, never married and had no children, siblings or other family living in the United States. Her English was poor.
Her neighbors knew she was feeling poorly, so they checked on her and found her unconscious on the floor. She was taken to the ER by ambulance. There were no signs of trauma but she was somnolent, dehydrated and jaundiced.
Despite hydration, she remained somnolent, unable to speak and developed irregular breathing. Physicians caring for her did not know her wishes regarding resuscitation, and there was no record of a health care proxy. They contacted her oncologist, who confirmed the advanced stage of her metastatic disease and the lack of any treatment, but he did not know her wishes regarding end-of-life care. She was clearly dying, but her medical team was unsure about what to do when she stopped breathing. An ethics consultation was requested.
Response: The most striking aspect of this consultation was the genuine uncertainty about what to do on the part of her caretakers. They felt obligated to resuscitate her even though they knew it was medically inappropriate. She was dying from a disease for which there was no further treatment, and resuscitation would be traumatic and not accomplish any worthwhile goal.
Resuscitation seems different from all other medical treatments, because it usually requires an order not to do it. In this case, for instance, there was no requirement to order no further chemotherapy even though that decision had been made. Her caregivers had the impression that in the absence of a DNR order, they were obligated to perform cardiopulmonary resuscitation (CPR), yet clearly the best medical care was to ensure a comfortable and peaceful death.
The caregivers’ genuine uncertainty reflects progress in making patient-centered care and shared decision-making a reality.1 Physicians and nurses a few decades ago would not have been puzzled about what to do: even though CPR was available, it was simply not performed in this situation. There was no need to inquire about a patient’s preference or seek a surrogate’s substituted judgment. Sometimes this plan was indicated by writing an order for a “slow code” or to “Page House Officer in the Case of Cardiopulmonary Arrest.” This course of action is no longer acceptable.2
An ethics consultation can accomplish four goals in this situation. First, the consultant can review and help confirm the validity of the supposed facts: untreatable, advanced metastatic cancer, no prior discussion of resuscitation preference and no surrogate. This goal was accomplished by assuring that the oncology team had been contacted and verified the underlying facts.
Second, the consultant can review the options and goals of treatment. This patient was clearly dying and in this circumstance with advanced cancer, resuscitation is virtually certain to fail and hence is futile. The outcomes of resuscitation for the past year at this hospital recently had been reviewed. The overall survival to discharge was 50 percent, but there were major differences depending on the patient’s condition and location in the hospital. More than 80 percent of cardiac surgical patients survived to discharge, but none of the 10 patients resuscitated on the oncology service survived. These differences are consistent with other reports and confirm the futility of CPR for this patient.3
Third, the ethics consultant can review with caregivers the hospital policy on resuscitation. The hospital’s policy required discussion before writing a DNR order but did not require resuscitation simply because a DNR order was lacking. Thus there was no medical, legal or hospital policy requirement to resuscitate her. A consensus statement by experts in CPR further clarifies this situation; they agreed resuscitation should be performed unless one of three circumstances exists: the person is already dead, there is a DNR order or resuscitation is not medically indicated.4 Our patient clearly falls in this last category.
A fourth goal of the ethics consultant is to bring this case to the attention of the ethics committee or body responsible for writing hospital policies, because revising the policy would help clarify what to do in these circumstances in the future. The policy was changed to explicitly state that when resuscitation is not medically indicated and it is impossible to discuss preferences with the patient or a surrogate, then resuscitation does not have to be performed. This makes it clear that resuscitation is similar to other medical interventions, but at the same time makes it important to discuss whenever possible.
This consultation also illustrated the need to discuss end-of-life care preferences with patients when they have decisional capacity. Some oncologists and physicians make these discussions routinely, while others find it difficult either because it takes away hope or takes too much time. In this case it was even more complicated because of the language barrier (interpreters are helpful, but the discussion is still difficult because of all the implicit meanings) and the presumed lack of a surrogate. Some have urged naming it an order to “Allow Natural Death” (AND) rather than DNR in these circumstances to avoid the negative connotation of giving up hope.5 Enlisting the aid of trained nurses, social workers or others may help physicians accomplish this important goal.
Lynn Peterson, MD
Senior Lecturer, Harvard Medical School Ethics Committee, Dartmouth-Hitchcock Medical Center
Outcome: The patient expired comfortably, approximately one hour after the consultation was called, in the presence of caregivers and the ethics consultant. No code was called.
Footnotes
1Dartmouth Atlas of Healthcare Web Site. Shared Decision Making Available at: http://www.dartmouthatlas.org/shareddecisionmaking/sdm_1.php. Accessed February 11, 2005.
2Gazelle G. The slow code – should anyone rush to its defense? N Engl J Med 1998;338:467–69.
3Ebell MH, Becker LA, Barry HC, Hagen M. Survival after in-hospital cardiopulmonary resuscitation. J Gen Intern Med 1998;13:805–16.
4Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. An International Consensus Science. Circulation 2000;102 (Suppl I):I-12-I-21.
5Cohen RW. A tale of two conversations. Hastings Cent Rep 2004;34(3):49.
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Dartmouth-Hitchcock Medical Center
The opinions expressed in the journal, Lahey Clinic Medical Ethics,
belong to the individual contributors and do not represent the institutional position
of Lahey Clinic on any subject matters discussed.
