Why physicians tend to decline CPR and other heroic measures

Radiolab recently aired a show called “The Bitter End” that discusses the end-of-life care preferences of physicians and non-physicians. Physicians are much more likely to decline “heroic” measures, such as CPR, mechanical ventilation, feeding tubes, etc. This comes as a surprise to the hosts and, presumably, to other non-physicians. It’s a good show. I recommend it. (Full disclosure: I like Radiolab.)

In the show, Ken Murray argues that physicians decline these “heroic” measures for intellectual reasons. He argues that we know the data, which includes a study that reported that, of people who receive CPR, only 8% are successfully resuscitated. (Of those 8%, only a portion of them return to their full previous function.)

I don’t think physicians decline CPR and other “heroic” measures because of evidence-based, numerical data alone.

The experience of performing CPR and attending to patients who are critically ill contribute to physician preferences against CPR. It’s emotionally taxing. All physicians have seen the trauma we cause with these “heroic” measures. Yes, performing CPR can lead to cracked ribs and punctured lungs. Mechanical ventilation can lead to severe cases of hospital-acquired pneumonia. Intravenous hydration can cause massive tissue swelling. The consequences of heroic measures are often devastating.

Physicians are taught “first, do no harm.” Sometimes, these heroic interventions seem like they cause more harm than good.

Perhaps physicians decline CPR and other “heroic” measures because of anecdotal experiences and emotions. This isn’t randomized, placebo-controlled data. However, anecdotal experiences and emotions are still data.

Furthermore, there is no true “informed consent” with CPR. When patients are able to consent to CPR, they are not truly informed. They cannot fully appreciate and understand what CPR entails because they have never experienced it.

By the time patients are truly informed about CPR—when someone is pushing on their chests, when a second person is manually inflating their lungs, when a third is injecting medications into their blood, when a fourth is trying to stick a breathing tube down their throats—they are unconscious. They cannot offer or withhold consent.

(This is true with many things in medicine: No one can give true informed consent for general anesthesia, surgery, or even medications. We often only know all the information after the fact. Patients often give consent based on hope and faith.)

Physicians see and treat patients who have undergone CPR. Those patients are usually paralyzed, swollen with fluid, and unconscious. Upon witnessing that, physicians might wonder what the differences are between “living” and “existing”.

This could explain why their end-of-life care preferences differ from that of the general public.

Maria Yang is a psychiatrist who blogs at In White Ink.

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  • Suzi Q 38

    A good friend of mine came from a big family of 12 children. Her father was an oncologist. He started having serious health problems in his 70′s, and had to go from a hospital to a nursing home. He never came home, because he refused a feeding tube.

    I was floored, although it is not my place to judge.
    To me a feeding tube is very basic. I guess to him, it meant prolonging the inevitable.

  • Mary Parker

    I love Radiolab, too. I’m a big believer in no CPR as well. I’ve seen and cared for the aftermath, for the family members who are convinced their loved ones are going to walk out of the hospital better than when they rolled in….When my time comes, let me go.
    For Suzi Q 38—a feeding tube with cancer can be more uncomfortable and fraught with complications than refusing the feeding tube. I’ve seen the aftermath of that, too.

  • drjoekosterich

    Good article. And yes there is a big difference between living and existing

  • bill10526

    My dad saw the stress that his sister-in-law, Doris, went through with chemotherapy. I think she got another 5 years out of it, then she passed from cancer. My dad declined surgery with good prognosis because he did not want to die twice like aunt Doris. He passed within a month of his decision.

    I was not aware of the actual horror of CPR on a terminal patient. Thank you for the post.

  • Dr.M.Mohan Rao.

    The best option for a Physician or anyone else is to write a living will that in case one becomes unconscious or not in sound mind to take decisions, CPR, use of life support measures like ventilator are not to be used. The document is to be given to all the close relatives. It is hell to remain alive as a vegetable!!

    • http://twitter.com/jlebling Dusty McDustin’

      How do you know? Maybe it’s fun being a vegetable? All kidding aside, when I grow withered and old there is no way in hell that I will accept being a bed ridden zombie patient. I probably will have something like that written up… Assuming I even live to be that old LOL