Imagine a scenario where an elderly person or a terminally ill patient’s heart stops. The emergency medical team gears up to perform cardiopulmonary resuscitation (CPR) but the chances of survival are slim. The paramedics are also unsure if the patient has Do Not Attempt Resuscitation (DNAR) orders. In a country where people tiptoe around the subject of death, the BioEthics unit of the Indian Council of Medical Research (ICMR) seems to have finally put an end to the dilemma amongst medical practitioners and patients about DNAR orders.
The current issue of the Indian Journal of Medical Research carries a position paper by ICMR's Bioethics unit on cardiopulmonary resuscitation and DNAR orders. ICMR confirmed that CPR is not a default option. Instead it is a medical procedure; certain circumstances it should not be done.
Matter of heart
CPR is a medical procedure performed to restart the heart and breathing of a person when it stops suddenly. In reality, only 2-18% of people who receive CPR survive.
Dr Roli Mathur, Head, Bioethics Unit, ICMR, says we need to have awareness programmes to make good end-of-life care and DNAR effective and implementable. Also, DNAR forms should be made available in all hospitals in regional languages. “Hospitals can constitute a board or group to work out the details. Frequent training and sensitisation programmes with all healthcare professionals involved in patient care need to be undertaken,” says Dr Mathur. The ICMR policy paper was developed after a series of consultation meetings held last year with relevant stakeholders.
It is no secret that for the past 50 years, Indian doctors have been conditioned to believe that CPR must always be done when the heart and breathing stop. “The assumption has been that if CPR is not done, this is potentially liable for legal action. Today’s publication clears up this ambiguity. It says that if it is likely that somebody may require CPR, it is good medical practice to inform the patient (if possible) and/or the family/surrogates about this possibility and its likely outcome,” says a statement issued by ELICIT, End of Life in India Task Force formed by three professional societies – the Indian Society of Care Medicine, Indian Association of Palliative Care and Indian Academy of Neurology.
Some facts about CPR
CPR is a medical procedure performed to restart the heart and breathing when it stops suddenly. “When performed in time on a healthy patient, it can be life saving. But this means that if it is performed on somebody who is already seriously ill, or if the procedure begins late for any reason, then it may not succeed. In fact it can lead to a terrible situation: the heart restarts but the brain is badly damaged by loss of blood circulation for a crucial period of time. In frail, ill and elderly patients it can be both, a traumatic and useless exercise, leaving behind broken ribs and unnecessarily prolonging death. The ICMR has confirmed that CPR is not a default option. Instead it is a medical procedure and in certain circumstances it cannot and should not be done,” says Dr Roop Gursahani, a leading neurologist and member of ELICIT.
According to Dr Mathur, the final decision on whether to perform CPR or follow DNAR orders has to be taken by the treating doctor(s) based on medical assessments. The treating physician should initiate discussions with the patient/surrogate and explain in detail about the patient's disease and its prognosis. The ICMR’s policy document describes the principles for DNAR, offers an algorithm and format for its implementation, and guidance on frequently asked questions.