To reduce unnecessary harm, staff in aged residential care facilities should not be forced to provide chest compressions to pulseless residents, University of Otago researchers believe.
They argue such facilities should be able to create and adopt informed 'no chest compression' policies, so that residents can have the staff holding their hand and providing comfort in their final moments. This benefits the patient, the caregiving staff, and the family.
Dr Janine Winters, of the Dunedin School of Medicine's Bioethics Centre, says the benefits of chest compressions for frail elderly people without a pulse are dubious and the burdens are high.
"Many people have a vision of chest compressions as care that miraculously brings people back to life, even people who are very sick. They see movies that show this. They watch – frankly amazing – footage of young people being brought back to life with chest compressions and they think it will also help people with end-stage disease and frailty.
"CPR is performed as a default and forgoing it at the natural end of life is often seen as 'giving up', but, in reality, rest home staff are violently breaking people's ribs as they die. In most circumstances, it is futile, as they die despite the procedure – as caregivers it's hard on our souls to have to hurt people who should be dying a peaceful death," she says.
Their research, published in the Journal of Bioethical Inquiry, was inspired by a New Zealand rest home which created a 'no chest compression' policy. After an audit, subsequent review, and no complaints, the facility was told it would be shut down if the policy was not retracted.
Dr Janine Winters
The researchers argue policymakers and regulators should allow aged residential care providers to implement such policies whereby, with pre-admission informed consent, no resident in the facility is offered chest compressions when pulseless.
"The conversation needs to occur before the crisis. It is difficult for some people and families to talk about their own mortality, but it is necessary to not have a default that hurts people," Dr Winters says.
All residents would receive standard choking care, and a fully discussed advance directive would be used to determine if a resident wanted a one-minute trial of rescue breaths to clear their airway, or for an automatic defibrillator to be used in case of cardiac arrest.
Emma Hutchinson, who co-wrote the paper as part of her undergraduate degree, says such a policy would remove added suffering from a person's end-of-life experience, and increase residents' understanding of the burdens of ineffective treatments for pulselessness.
"The benefits of CPR, specifically for those who have not suffered a sudden cardiac arrest, are greatly overestimated by the public, and the harms are overlooked.
"People need to understand it is not the miracle treatment that it is portrayed as in the movies, and while it certainly has its place, this overestimation and miseducation creates barriers to informed consent," she says.
CPR has a range of potential outcomes including death, physical disablement, and severe brain damage. When used in its correct, intended circumstances – for healthy patients who have suffered sudden cardiac arrest – it can be highly effective.
"However, many aged care facility residents with co-morbidities are not those it was intended for – CPR is constantly being used outside of its scope."
Emma Hutchinson
Their research found that confusion about language describing CPR and resuscitation, time constraints and a fear of frankly discussing the violence of chest compressions commonly discourages doctors from bringing up or encouraging sensible limits on specific resuscitation measures. Discussions are usually done quickly and are based on box ticking a form rather than considering a good death, intended purpose of CPR, and the realities of undergoing chest compressions.
"There is no consent needed for chest compressions but there are multiple hoops to be jumped through to consent to not having them, which is an anomaly in the medical world," Ms Hutchinson says.
She was motivated to undertake this research soon after her father passed away from a chronic illness.
"He told us he didn't want CPR performed on him which I initially found upsetting because it felt like he was giving up on a chance at prolonging his time with us. However, through some hard conversations with him, my mindset and my understanding of what CPR is intended for, changed.
"We need a more holistic approach to death in aged care facilities – life prolonging care at all costs should not always be the primary focus. Residents need to receive appropriate and helpful medical and comfort care, with the option of dying with staff by their side instead of on their chest."
Publication:
J. P. Winters and E. Hutchinson
Journal of Bioethical Inquiry
