The Ethics of Resuscitation
A Brief History and Center for Practical Bioethics’ Efforts to Improve CPR Outcomes
Promise and Problems
Cardio-pulmonary resuscitation has offered food-for-thought for philosophers and bioethicists from its beginning, and the Center for Practical Bioethics has a long history of grappling with this subject.
In 1966, the National Academy of Sciences reported that closed chest cardio-massage and CPR should be ordinary treatments for hospitalized patients. Before that, CPR was a “hit-and-miss” proposition. Through the 1970s and 80s, the use of CPR became more prominent in hospitals, and CPR expanded to include defibrillation. In 1984, the year the Center was incorporated, Johns Hopkins Hospital became the first to incorporate automated external defibrillators (AEDs) into resuscitation efforts.
CPR was original intended for those who experienced cardiovascular arrests that were witnessed (i.e., those who died of a heart attack observed by someone with CPR skills). By the late 1980s and early 90s, it was being applied to all those who died in hospitals – and raising questions. One writer referred to it as “medical creep.” Another said, “Resurrecting the dead became medicine’s obsession.” Another referred to death itself as a “recurrent problem.”
The Center for Practical Bioethics and others imagined that issuing do not resuscitate (DNR) orders would protect patients, who had little to no chance of benefiting from CPR, from the harms that can result when CPR is used inappropriately. Typical among these harms are broken ribs, burned skin, massive bruising, and being caught between life and death with little “quality of life.” Ron Stevens, MD, then head of Oncology at the University of Kansas, said that CPR was the “least aesthetically pleasing intervention done in medicine.” Another physician, one of the Center for Practical Bioethics’ “near founders,” Bill Bartholome, MD, wrote an article for the Annals of Internal Medicine in 1988 in which he said, “What is needed is a new perspective, a new way of thinking about Do Not Resuscitate Orders (DNR). We need to come to understand that in most tertiary medical centers and nursing homes the only predictably good candidates for the use of CPR’s techniques are staff and visitors.”
For the most part, DNR orders were recognized in hospitals, but as, Medicare and state regulatory surveyors saw resuscitation as a quality measure, physicians were often hesitant to write such orders in particular for frail, elderly patients without capacity and/or when families were demanding that “everything possible be done.” And when patients who did have a DNR order left the hospital, there was no way for the DNR order to follow them home.
New Guidelines and Strategies
The Center for Practical Bioethics and others recognized that the near universal practice of attempting to resuscitate everyone who died in a hospital was ethically flawed and that questioning CPR in peer-reviewed journal articles and its efficacy at professional conferences was not enough to safeguard patients.
In 1988, the Kansas City Regional Hospital Ethics Committee Consortium convened by the Center followed the lead of a community-based project in Hennepin County Minnesota that created a way for DNR orders to expand beyond the hospital settings. With our emergency medical service providers, local hospitals and nursing homes, Kansas City became the second community in the country where patients at home could have a DNR order that would be honored. The Kansas City initiative was featured in the Annals of Emergency Medicine.
The Consortium also created policy guidelines for DNR Orders in Nursing Homes and for Honoring DNR Orders During Invasive Procedures. The Spring 1998 issue of Bioethics Forum contains these Consortium guidelines. Because of this work, the Joint Commission (then JCAHO) sought the Center’s help in developing their standards.
POLST and Beyond
That same year the Center became aware of POLST (Physicians Orders for Life Sustaining Treatment) in Oregon, which expanded from unwanted and potentially harm treatments statewide. In 1999, the Center published a policy brief reporting Oregon’s initiative in Issue 3 of its publication, State Initiatives in End-of-Life Care. Implementing a POLST-like project in Kansas City has been challenging because our community straddles the state line. Today, the Center in concert with large healthcare-providing institutions leads a similar project called Transportable Physicians Orders for Patient Preferences (TPOPP). It is the first bi-state “POLST paradigm” initiative in the country. TPOPP educational materials and resources can be found at practicalbioethics.org.
The Center’s work in this area has long included inviting scholars from across the country to speak about their research and writing on this topic. On August 12, 2015, 7:00 pm, we will continue providing education and opportunity to learn from national scholars and one another when David Casarett, MD, presents the 21st Annual Rosemary Flanigan Lecture at St. Joseph Health Center in Kansas City, Missouri. Dr. Casarett is a tenured professor at the University of Pennsylvania Parelman School of Medicine and the author of Shocked: Adventures in Reviving the Recently Dead, a complete history of CPR.
By Myra Christopher and Rosemary Flanigan, PhD
SHOCKED: Adventures in Bringing Back the Recently Dead
August 12, 2015
Reception 6:00 pm
Lecture 7:00 pm
St. Joseph Medical Center
Alex George Auditorium, Building D
1000 Carondelet Drive, Kansas City, MO
David Casarett, MD, associate professor of medicine at the University of Pennsylvania, will explore the history, science and moral hazards of reviving the “recently dead.”