VOL: 98, ISSUE: 25, PAGE NO: 36
Robert Dingwall, PhD, is professor of sociology and director of the Institute for the Study of Genetics, Biorisks and Society, University of Nottingham; Ann Shuttleworth, BA, is a freelance health care journalist
Cardiopulmonary resuscitation is one of the great unquestioned practices of modern health care (Timmermans, 1999). When ethicists talk about resuscitation, it is only to explore the circumstances in which it may not be appropriate. They assume that CPR should always be attempted unless special conditions apply: either the intervention is clearly futile or the patient has made an advance directive stating that they do not want to be resuscitated. This article looks at where this assumption originates and how it relates to the actual success rates of CPR. Could it be that CPR often wastes scarce health care resources and infringes on patients’ rights not to undergo inhuman treatment? Perhaps the assumption should be reversed: CPR should not normally be attempted unless there is good reason to expect it to be successful.
Why do we assume CPR should be attempted?
In the UK, this assumption has ethical, legal, professional, political and cultural sources. The ethical argument is based on three principles:
- The ‘rule of rescue’: the human urge to rescue identifiable people facing avoidable death, without considering the cost of doing so either to the person or to society (Jonsen, 1986; Richardson and McKie, 2000). Failure to rescue a person from avoidable death may well lead to criticism, even if to do so may endanger the rescuer (as in the case of saving a drowning person). At the same time, society accepts countless other avoidable deaths of unidentified people as ‘the way of the world’;
- Duties to neighbours: we have a moral duty to help those known to us or close to us. This extends to patients in the care of health professionals - patients are seen as having a moral claim to treatment;
- Beneficence/non-maleficence (to do the patient no harm): the belief that to save a person’s life is by definition to do good.
These principles tend to be reflected in the ethical codes of health care professions. Failure to save a person from ‘avoidable death’ could be described as failure to care for patients properly, and is cited as an example of misconduct by the UKCC (1998) and its successor, the Nursing and Midwifery Council. It could also be seen as a breach of the Code of Professional Conduct’s (UKCC, 1992) requirement that practitioners should promote and safeguard patients’ interests and ensure that no action or omission is detrimental to the interests, condition and safety of patients. Health care professionals who fail to attempt CPR could find themselves the subject of a complaint of professional misconduct by the patient’s family. This is likely to lead to investigation by their registering body - even if they do not face legal proceedings - and possibly to their removal from the professional register.
Legally, the position is less clear-cut. British courts have traditionally been respectful of medical discretion and reluctant to force doctors to carry out actions they believe to be of marginal benefit. Although there are a number of civil liabilities and criminal charges that doctors could face, it is unlikely that a decision made in good faith and on a non-discriminatory basis would result in successful litigation. However, the courts seem likely to insist on this being a doctor’s decision. CPR often takes place simply because there is no one present who feels they have the legal authority and expert knowledge to say it is a waste of time.
Politically, the NHS has been subjected to heavy lobbying, particularly from groups representing older people who see non-resuscitation policies as potentially discriminatory. This has been reflected in the NHS Executive’s (2000) resuscitation policy, which recommends the joint statement on CPR by the British Medical Association, Resuscitation Council and RCN as the basis for the policies trusts are now required to have. Trusts are expected to ensure that they have explicit policies, that staff are trained in CPR and that their performance is subject to audit. The NHSE justifies its policy as a protection of patients’ rights, although it fails to define these.
Perceptions versus reality
The pressures on the NHS from patient advocacy groups partly reflect wider cultural images of CPR. Many come from television series such as Casualty and ER, which regularly show it being performed on patients. However, the results of CPR as portrayed in the fictional A&E units are misleading. A US study of three series, ER, Chicago Hope and Rescue 911, found that most arrests depicted were owing to trauma and occurred in fit, healthy children and young adults (Diem et al, 1996). Seventy-five per cent of patients were resuscitated and 67% left hospital neurologically intact. UK series seem to show lower success rates, yet they are still far removed from situations with which most health care professionals are familiar.
The reality experienced by health care professionals is that most CPR is performed on older patients - the average age seems to be in the late sixties - who have pre-existing medical problems and a relatively short life expectancy. Even under the best conditions, where the arrest and CPR both take place in hospital, independent circulation is re-established in no more than 30% of patients. Most will die shortly afterwards from another cause, or suffer significant neurological impairment. At best, only half the patients will survive to be discharged from hospital with their faculties reasonably intact (Varon et al, 1998).
In the community, the prospects are even worse. About 8% of patients will re-establish a heartbeat, and only a quarter of these will survive to discharge (Varon et al, 1998). Despite investment in community education for CPR, and in the recent provision of automatic defibrillators, these figures have changed little in the past 30 years.
What does it cost?
While there is a lack of data for the UK, the relativities shown by US data are probably applicable here. Because resuscitation is mostly carried out on older people with short life expectancies, for each person resuscitated the cost was around $250,000 (£170,000) per quality-adjusted life year (QALY) gained in the mid-1990s (Lee et al, 1996). For comparison, babies in neonatal intensive care cost around $8,000 per QALY, angina patients receiving coronary artery bypass grafts cost around $64,000 and the provision of routine antihypertensive medication to 40-year-olds costs $16,500 per QALY. In the UK, the National Institute for Clinical Excellence currently appears to use a benchmark of £30,000 per QALY to evaluate whether new drugs should be accepted for NHS use. If CPR were evaluated by NICE, it is unlikely that it would be performed nearly as often.
The ethics of taxation
The NHS certainly has an ethical duty to save life. However, it also has an ethical duty to use its resources effectively to maximise the number of lives saved for a given level of resources. This is particularly important in a tax-funded system, although it also applies to some extent in insurance-based systems. The difference between taxation (the legitimate transfer of resources between citizens to achieve collective goals) and extortion (the corrupt abuse of power by the state) is the extent to which money from taxation is spent more efficiently and effectively than taxpayers could spend individually. The same principle applies to insurance, where the insurance provider has a duty to those who pay premiums to ensure that benefits are paid only where they fall within the terms of the coverage and to the minimum extent necessary to treat the condition. UK medical ethicists have had little to say about these issues but they are vital to understanding what makes the NHS a legitimate means of redistributing resources from the healthy to the sick.
Many current debates about NHS funding, for example, concentrate on the fact that we pay less for our health service than many other European countries, and that the service we receive is worse. However, when assessing how much money we spend or how much we should spend, it is important to look at the value delivered for that money. For example, European systems often have short or no waiting lists because their hospitals operate at 60-80% of their potential capacity. This explains why French and German hospitals have been able to take British patients in the recent government initiative to cut UK waiting lists. However, empty beds cost money. In a tax-funded system, that money is being wasted. It could be allocated to other social uses, such as education or transport. Alternatively, it could be left in citizens’ pockets for them to use. If the UK had that level of bed occupancy, hard questions would be asked about the legitimacy of taxing people to pay for the unused capacity.
Every time patients receive futile treatments, with little or no hope of restoring them to health, others are denied treatments of proven benefit. Some ethicists argue that this challenge can be ducked by increasing NHS funding so that futile treatments do not compromise beneficial ones. But this undermines the moral bargain between governments and taxpayers: that governments will use tax revenues efficiently and effectively. Futile treatments, which most attempts at CPR seem to be, are intrinsically unethical.
Don’t patients have a right to resuscitation?
Professionals providing CPR undoubtedly do so because they believe it is in the patient’s best interests. They may even argue that patients have a right to be treated in this way. However, resuscitation is frequently not in the patient’s best interests and may contravene another right, that they should not be treated cruelly. The principle of universal CPR often simply postpones death and makes it far less dignified. Is there any justification for crushing an elderly person’s chest to the extent that they die of pneumonia a few days later owing to injuries sustained? Equally, is there any justification for condemning someone to a life of neurological impairment and dependence, simply because we did not ask whether they would prefer this to death?
Reversing the default assumption
It may be time to rethink the assumptions of universal CPR. Should we be trying harder to predict who is likely to survive CPR in reasonable condition? Anecdotally, for example, it seems that most arrests in theatre, which receive immediate CPR, have a good prognosis unless there is a serious underlying disease. If this is the case, perhaps we should assume that unless there is a positive reason not to do so CPR will be carried out after theatre arrests.
In the community, however, the logic may be different. While bystanders should not be discouraged from attempting CPR, even in the face of professional knowledge of the futility of their efforts, paramedics need to have more authority to determine whether their intervention will be pointless. They should not be expected to attempt resuscitation in the absence of a heartbeat when they arrive on the scene. Again, further research may suggest specific occasions on which this assumption should be overridden, based on the probability of survival. When young children fall into very cold water, for example, and their body temperature suddenly falls, there is a sufficient chance of full recovery to justify sustained effort at resuscitation.
In hospital, though, the emphasis should shift from CPR - an intervention after an event - to preventive treatment. There is emerging evidence of the benefits of specialist medical teams who can be called in to deal with patients who have unstable cardiac rhythms (Buist et al, 2002). A more effective use of resources might be to enable nurses to monitor the cardiac output of at-risk patients to identify problems before they lead to cardiac arrest.
Patients who do not respond to preventive interventions are certainly unlikely to respond to CPR, so it should not be performed if they arrest. However, this will be based on a prior specialist assessment of the likelihood of the success of CPR.
Giving up the ghost
A move from routine CPR will involve a significant shift in legal, political, professional and public thinking. This will not be achieved without honest assessment of the efficacy of CPR and its costs to the NHS and to patients. In the field of transplantation there is talk of a move towards assuming people agree to donate organs on their death unless they opt out beforehand.
Perhaps in the case of CPR people should ‘opt in’, by making an advance directive that they wish to receive it even if they are unlikely to survive for a significant length of time. We would then be condemning fewer people to spend their last days or months in pain or debilitation when they have no hope of recovery and no reasonable quality of life. We would also be releasing resources for people who are genuinely able to benefit.