As the saying goes, there’s only two certainties in life: death and taxes. While it is true everyone will die someday, modern medicine has advanced to the point where we can keep people physiologically alive well beyond the point of any meaningful functional recovery. But just because we can potentially restart patients’ hearts after they die and make them dependent on ventilators and vasopressors, does that mean we should?
Descartes’ famous cogito ergo sum – I think therefore I am – philosophy would argue not. At the same time, once in a while, we hear about extraordinary stories like this one. It is no wonder that the medical profession is constantly struggling to refine a concrete approach to end-of-life decisions. Arguably, the most difficult one is whether to always start CPR (despite an exceedingly low rate of return to functional status) and attempt full resuscitative efforts on patients when they make the transition from life to death…otherwise known as a full code.
The current practice is North America is this: a patient is full code by default. Regardless of whether you are a young previously healthy individual involved in a life threatening car crash, or an elderly demented nursing home resident suffering from end-stage metastatic cancer, if we witness you suddenly losing vital signs and die, we go full tilt – that means rib cracking chest compressions, intravenous vasoactive drugs, breathing tube down the wind pipe. Sounds aggressive? It is. In fact, the success rate of such resuscitative measures (after someone has technically died) is so low, that many experts are questioning whether we are doing more harm than good…not to mention the utilization of many healthcare dollars.
Recognizing that full code is practically futile in some circumstances, many institutions have in place a practice of code discussions with patients and families. The idea is that upon admission into the hospital, the goals of care surrounding possible end-of-life events are discussed and agreed upon, thus clarifying for the healthcare team what actions should/should not be taken in case of death. But it doesn’t work as well as it sounds. For instance, this particular study found that such discussions are often poorly done and laced with many inconsistencies; and in fact end up falling back to the default full code whenever there is uncertainty around code status.
Recently, the pendulum has swung even more to the other end with suggestions that perhaps the default shouldn’t be full code at all, but no code instead. Check out this recent opinion piece applauding an article published in the Journal of the American Medical Association (JAMA). The authors go as far as recommending that “…not offering CPR for imminently dying patients should be explicitly permitted by hospital policy…”.
But perhaps it is unrealistic to make a blanket policy that is applicable to every patient. As a society we can easily appreciate that even the mildest medical ailment might affect each individual person differently; for example, someone with a viral cold will experience and recover from it differently than another person. Is it too much to ask for us to recognize that each patient’s death, and how they wish to be resuscitated or not, is just as variable between individuals?
Furthermore, this is not simply an issue of “saving someone’s life” versus “letting them die” – there may be tremendous benefits in the act of performing resuscitative measures in and of itself. Emerging evidence suggests that there is therapeutic value in “going full tilt”, and that perhaps we should be allowing family members in the room to witness resuscitative efforts.
I still clearly remember the last time I intubated a patient despite a no CPR code status.
A patient with metastatic lung cancer was brought into the ER with what looked like a severe pneumonia on X-ray – he was breathing very rapidly in a losing battle to get more oxygen, to the point where he was barely conscious. Incidentally, the patient had a code status discussion with his family just a few days ago, and clearly documented in his chart were the instructions to not proceed with CPR or insertion of a breathing tube in the case of impending death due to his invasive cancer. However, it provided no guidance as to what we should do in the event of a potentially reversible medical condition (which in this case was a severe infectious pneumonia, typically treated with giving antibiotics and temporarily putting patients on a ventilator to assist their breathing)…although the chance of his survival even with aggressive interventions was extremely slim.
I turned to his daughter for guidance, but it was clear from her eyes the internal turmoil that was ravaging her soul – she did not want to be the person to “let her father die” from a potentially reversible condition, regardless of how slim the chances of success were. It was clear to me then what I should do, although some of the nurses disagreed. The patient was intubated smoothly and put on a breathing machine to ease his respiratory efforts, so that he was no longer gasping desperately against his pus-filled lungs. Appropriate antibiotics, sedation, and pain medications were administered promptly. He died comfortably several hours later – no attempts at CPR or resuscitation medications were given.
His daughter came up to me afterwards. Her eyes, while teary, no longer reflected the anguish from earlier – it was as if a huge weight has been lifted. She softly said two words: Thank you. And then she hugged me. Right there in the middle of the resuscitation area.
Neither Full code nor No code, I left that ER shift knowing that I did the Right Code.
Edmund Kwok
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