The Indian Council of Medical Research recently drafted a position paper on Do Not Attempt Resuscitation (DNAR) orders for medical practitioners in India.
You have seen CPR (cardiopulmonary resuscitation) in movies and TV shows. Someone has a cardiac arrest or goes through trauma (electrocution, drowning etc…). A hunky hero or some burly bystander pulls the victim to safety and starts pounding on his/her chest with all his might, breathing into his/her mouth, etc. A few coughs, some jerks, eyes open and within a jiffy the victim bounces back to life, as if nothing had happened. But in reality, only 2% to 18% of people who receive CPR survive.
According to some senior doctors and studies, more often than not, untrained people, including paramedics, sometimes end up breaking the ribs of patients while performing CPR on old dying patients. Of course, all this with the good intention of saving the life of a person! And despite the rescuer's best efforts, death is by far the more common outcome.
The Indian Council of Medical Research recently drafted a position paper on Do Not Attempt Resuscitation (DNAR) orders for medical practitioners in India. Throwing some light on the subject, Dr Nagesh Simha, a palliative care physician from Bengaluru, who is also member of the steering committee of ELICIT, an inter-speciality taskforce on End Of Life Care in India says, “Death is inevitable in case of elderly patients and those with terminal illness. By performing CPR on them, you may revive their heart but in the process damage their ribs and quality of life if they survive.”
Dr Simha explains that the brain needs oxygen supply and if that doesn't happen, there could be irreversible damage. “Worse part is, the patient is dying and you are making death even more painful instead of letting him/her pass away in peace. Hence, the importance of DNAR orde,” he says.
Matters of the heart
There is no doubt that CPR is given to keep you alive but there's no guarantee that your ribs will be in one piece, especially if you are old, feeble and suffering from some terminal illness. Citing the ‘effect’ of CPR on an old dying patient, Dr Roop Gursahani, a leading consulting neurologist at PD Hinduja Hospital & Research Centre, Mumbai says that recently during his morning rounds, there was commotion outside the female general ward. Code blue had been paged and few resident doctors and nurses were running all over attending an 86-year-old patient.
Much to his dismay, it was Ms Nancy (name changed for privacy), his patient for four years — small, frail, cheerful and with progressive dementia. Nancy could not name the daughter who cared for her or recognise the older son who paid for her treatment because of her dementia. She was admitted in the hospital two days prior for bad pneumonia.
“Nancy's family and myself had discussed whether or not to move her into the ICU or to sign a Do Not Attempt Resuscitation (DNAR) order. But her children had not yet decided,” recollects Dr Gursahani.
He reached Nancy's bedside, when CPR was already in process. A burly paramedic was compressing her chest and he could hear her ribs crack. Another doctor was preparing to insert an endotracheal tube into her windpipe to breathe for her. Since the heart was still not beating, defibrillator paddles were applied and she was shocked. “Her heart and breathing restarted but she remained unconscious. The team began the process of moving her into the ICU,” says Dr Gursahani.
Later that afternoon, in the ICU, Nancy's heart stopped again. But this time her son and daughter mentioned that they were against CPR being performed on their dying mother. They wanted her to pass away in peace. The hospital staff respected their DNAR order and did not perform CPR the second time. Nancy passed away in peace.
“Most lay persons and even doctors are not aware that after the age of 50, very few people die suddenly. Most deaths are predictable in a broad time frame and everybody has the right to decide whether their last moments should be peaceful or fought till the end. As shown in many surveys around the world, most of us would prefer the former, passing away in our own beds and in the company of our loved ones,” explains Dr Gursahani.
The basic principle of CPR begins as a rescue mission, based on beneficence, of doing good, where even a bystander can rescue a fallen fellow human. In this sense, CPR needs to be learnt by everyone.
For example, CPR saved the life of a young cricketer, Amit (36) (name changed for privacy) in Delhi, when he suddenly collapsed on the ground. It was a lazy winter Sunday morning and cricket teams were at play on a Delhi maidan, with cries of ‘Howzzat’ and thwacks of bat on ball ringing around. When Amit collapsed and lay motionless without any pulse, there were two doctors on the next pitch, who rushed and performed CPR on him. One of the doctor’s straddled him, thumped his chest hard and began the external cardiac massage of CPR. The other extended Amit's neck, pulled his jaw forward and prepared to give mouth-to-mouth breaths. And then Amit's eyes fluttered open and he took a spontaneous breath. He was rushed to a nearby hospital where emergency angioplasty salvaged the situation.
According to Dr Gursahani, Amit was saved because he was young and in otherwise good health. Also, because someone trained in CPR had been at hand. In Amit's situation, CPR truly was a lifesaver.
But what when it is predictably unnecessary and excessive at the end of life, like in the case of Nancy? “Doctors should discuss the pros and cons of CPR procedure and DNAR with the patients and their family. Doctors must engage with patients and their family and explain to them the line of treatment. Patients have a right to determine what works for them and if they choose DNAR then we should respect their choice,” says Dr Raj K Mani, an intensivist, pulmonologist and MD of Batra Hospital & Medical Research Centre, New Delhi.
The procedure of CPR was devised in 1960. Over the past six decades it has been spread worldwide as part of the ACLS courses, which train millions of doctors, paramedics and even lay people.
The benefits have been incalculable in terms of lives saved. “When we trained as resident doctors decades ago, we were informally taught that CPR should be performed on every patient before death could be certified. So over the decades, in Indian hospitals, it became a ‘Death ritual’ performed on dying patients, as though it is obligatory. However, to not perform CPR requires knowledge of the forgotten science of prognosis. We need to recognise those in whom CPR is useless or worse. We also need to integrate the patient's expressed values and wishes,” says Dr Simha.
Nothing to Fear
Sometimes people have genuine concerns. What if a person dies after a bystander or Good Samaritan performs CPR? Will they be sued? As a bystander, you are unlikely to be sued for performing CPR. At times you come across news where CPR-certified paramedics are prevented from providing CPR to a patient. That's because the patient has a DNAR order, and the family and doctors respect the patient's end of life care wishes. “Social conscience is driven by rationality, not by fear. If you follow ethics and desire to do good then you need not fear about anything,” asserts Dr Mani.
Worldwide doctors have been socialised against categorically stated prognosis. This is because an empowered patient or family is unwilling to accept an oracular pronouncement. They want doctors to foresee and discuss the road ahead with honesty, accuracy and optimism. Dr Mani, who is an advocate of end of life care, adds that many lay persons are not aware of the basic principles of bio-ethics as applied to medicine. “They are autonomy, beneficence, non-maleficence and justice.” Doctors who are not taught the specific skills of communication of this nature might find this too intellectually and emotionally challenging.
And those who will not commit to foretelling eventually find that their foresight has vanished. “But if I recognise what is coming and my patient is prepared for his/her death, neither hastening nor delaying it, together we can ensure a peaceful death consistent with his/her values and wishes at the end,” says Dr Gursahani.
As much as we love to read about medical miracles and watch medical-themed shows on our TV screens, sometimes it is funny to watch hysterical actors perform CPR. For example, in Janasheen (2003) a skimpily clad Celina Jaitly gasps for breath after a villain covers her face with a plastic bag and leaves her 'almost dead'. But rescue comes in the form of a bleary-eyed Fardeen Khan. He performs 3-4 chest compressions and gives mouth-to-mouth breaths. And Voila! Celina bounces back to life singing praises, ‘I love you…I love you’.
Hollywood's obsession with heart and absurdity is not far behind. In Crank 2 High Voltage (2009), a dying Jason Statham holds a paramedic at gunpoint, and forces him to shock him with defibrillators to keep his weak heart ticking. Some high voltage stuff indeed!
According to experts CPR is more than just pounding someone's chest. One needs to check the victim's breathing, pulse, tilt his/her head. The person giving CPR also needs to assess the victim's age, health and current situation. In reality, you may need to pump in 100 to 120 compressions each minute to perform CPR correctly. Needless to say, extremely taxing and exhausting for any fit person, the reason why paramedics take turns to perform CPR. Also, sometimes it can be emotionally draining if you perform CPR and the patient does not survive. However, experts suggest that the first thing you need to realise is that CPR is meant to give a person a better chance at survival while medical help arrives. If he/she does not make it, that does not mean it is your fault.