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• W2028883846 abstract "To the Editor. — It was no surprise to learn from the excellent study by Applebaum et al of the bleak outcome of cardiopulmonary resuscitation (CPR) initiated in the nursing home.1 Given such data, other procedures would be relegated to antiquity. Thus the authors' proposal that CPR be withheld from all nursing home residents is understandable. However, nursing home populations are not necessarily homogeneous, and this across-the-board decision would deprive the very few who might benefit from CPR of a choice in the matter. Moreover, by isolating from other therapeutic measures this widely known and emotionally laden procedure, this proposal complicates the process of developing a comprehensive health-care plan for the individual in a nursing home. Cardiopulmonary resuscitation differs from other medical procedures in that its use has been taught to the lay public for the bystander who witnesses an out-of-hospital cardiac arrest.2 It is not clear that the elderly fare worse than the young in out-of-hospital cardiac arrests, particularly in certain subsets of patients.3,4 A few individuals in these subsets may reside in nursing homes, particularly those with short-term rehabilitation units. It certainly could be argued that such an individual should be allowed to have CPR if desired. Because of the widening of media coverage of death and dying issues, many residents and their families may be familiar with CPR. Anticipating questions and addressing concerns that might not always be voiced is an important skill of the geriatrician. I offer the analogy of a patient with lung cancer determined to be inoperable by staging criteria. The patient may be fearful of being subjected to surgery or of facing his or her own mortality. In either case he or she may be reluctant to broach the subject for a variety of personal reasons. Anticipating this, an experienced physician would take the initiative to raise the subject. This would provide an opportunity to address not only this specific issue, but also to begin discussing prognosis and plans for future therapy. Similarly, because of lay awareness of CPR and the symbolic baggage it carries, its discussion may provide a platform for discussion of broader treatment issues relevant to the nursing home resident. Whether to attempt resuscitation constitutes only a fraction of the therapeutic decisions that may confront the nursing home resident. Other modalities considered may include feeding tubes, intravenous catheters, antibiotics and other medications, and the transfer of the patient to the hospital for acute illness. Although every potential future medical intervention cannot be anticipated and discussed with the resident (or the family in case of cognitive incapacity), many can. Furthermore, the resident's basic values, goals, and attitudes toward quality of life can be assessed to provide a framework for making future decisions. The resident, for instance, may choose to avoid hospitalization for pneumonia and accept treatment only in the nursing home.5 For many patients, particularly those with advanced dementia, a hospice approach may be appropriate and desirable.6–8 The issue of resuscitation may assume less importance than the use of feeding tubes, hydration, or antibiotics. It certainly would not seem consistent for a patient to decline the use of antibiotics for an infection but to desire CPR for a cardiac arrest. Thus these issues must be addressed in the context of a comprehensive health-care plan developed with the individual resident and family. This should address not only which specific interventions the patient prefers to avoid, but, as Lynn so eloquently asks, “What kinds of futures can be provided and which ones would (or does) he or she prefer?”9 If CPR is not consistent with the patient's health and quality-of-life goals, particularly given its bleak outcome, this can and should be conveyed to the patient by the physician. Although authorization of do-not-resuscitate orders is within the patient's rights, the physician is not obligated to present the issue in an unbiased and unemotional fashion. The patient may look to the physician for strong guidance in such critical decisions. Both Murphy and Wagner reported that, given a somewhat graphic description of CPR, its potential complications, and expected outcome, few patients consented to attempted resuscitation.10,11 Furthermore, Wagner found that the vast majority of residents originally requesting CPR or deferring to physician discretion subsequently changed to “no CPR” on an annual review.12 Thus, with appropriate information and sufficient time, was it unreasonable to include residents in this very serious and personal decision? Fader et al found otherwise, but it may have been due to the “unbiased process” utilized as well as the large number of surrogates involved in decision making.13 It is not heavy-handed to provide a graphic description of resuscitation and its outcome (perhaps using Applebaum's data), an illustrated leaflet, or even an explicit videotape. These media are frequently used to educate patients about surgical procedures. If a physician can urge a patient to sign consent for a badly needed coronary artery bypass graft, why not for an authorization for a do-not-resuscitate order and other advanced directives? An additional reason for eliciting preferences regarding CPR is to protect the patient's prerogative should he or she be transferred to another facility. An institutional ban on CPR in the nursing home might not be honored in a hospital emergency room, should a resident be transferred. In this author's experience, it is not unusual to be called to evaluate a nursing home resident in the emergency room who has already been resuscitated and intubated and to discover subsequently from the family that this was contrary to the patient's wishes. Clearly, “when in doubt, resuscitate” is the prevailing attitude. Although there is always the potential for unforeseen situations, comprehensive advanced directives including preferences on CPR would go far toward ensuring that patients' choices will be known and honored. Developing a comprehensive care plan for the nursing home resident is certainly time-consuming for the physician.14 However, in proposing that nursing homes ban CPR, Applebaum et al admit that “informing prospective residents about this policy and its rationale could virtually require a physician's presence.” In either case, a physician's time will be required. Better that it be used in tandem with nursing and social work personnel to coordinate a rational, comprehensive, and individualized health-care plan including CPR preferences than to present an inflexible institutional policy to prospective residents." @default.
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• W2028883846 date "1990-10-01" @default.
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• W2028883846 title "An Additional Letter on CPR in Nursing Homes" @default.
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