Withholding treatment

Resuscitation can mean different things. Here it’s taken to mean cardiopulmonary resuscitation (CPR). This is defined as the attempt to restore a heartbeat in someone whose heart has stopped beating and the attempt to restore breathing in someone who has stopped breathing.

Decisions about resuscitation take into account many factors, a major one being the underlying reason why the heart stops. This in turn determines CPR’s chances of success, and the possibility of damage from the procedure.

CPR was originally intended for situations when a stoppage is caused by a problem with the heart itself. In these cases, the rest of the body functions normally up to that point. In this scenario the chance of CPR restoring heartbeat is at most 10%. There’s risk also of brain damage if the brain has not had enough oxygen while the heart was stopped. Even when CPR works, people are on life support for some time afterward and sometimes can’t survive without it.

Over the years, the use of CPR has broadened to include a wide variety of medical situations. It’s clear now that the greater the general health problems, the less the chance that CPR will work. In terminal illness, there’s a relentless decline throughout the body. In the final days, people tend to sleep most of the time, complications are common, breathing becomes weaker and it finally stops. A few minutes later the heart stops. This is the natural process of dying from a progressive terminal condition. In such circumstances attempts to restore heart function do not work. The heart has stopped because of the burden of illness on the entire body. All body systems are shutting down and are not available to support heart function.

Some people believe that CPR offers hope. Such hope, however, is not useful if there’s no chance of restoring heart function. The resuscitation procedure is complex, costly, labour intensive (involving many health care providers), and causes physical damage to the patient. Such a demanding procedure should not be performed when there’s no chance of success. Physicians are not obliged to provide treatment that can’t possibly work, and the ethics of doing so are questionable. For example, a surgeon can’t be expected to perform surgery that has no chance of success; a physician can’t be obliged to prescribe medication whose use is not supported by evidence.

When discussing resuscitation decisions, open and honest communication is essential. Honesty is a key element in developing trust and offering care. It is not honest to offer CPR as an intervention that offers hope in the end stages of a terminal illness. Occasionally, this view may create disagreement among the patient, their family and the health care team. If conflict arises, it must be addressed. Often this involves obtaining a second opinion from another physician. If the second physician doesn’t support the first physician’s decision, then care may be transferred to the second physician.