CPR without informed consent in the elderly

Agnes was out shopping at her local corner store.  At age 82 her body was beginning to show typical signs of aging.  She had survived breast cancer surgery, a hip replacement, and cataract surgery.  Her doctors told her she had osteoporosis and low vitamin D.  She took medications for her hypertension, cholesterol, and osteoporosis.  Her spine had begun to curve and her gait was a few steps slower.

Yet, with her shopping cart she still enjoyed her trips to the store.  Her best friend had suffered a cardiac arrest recently and didn’t survive the hospital stay.  She discussed this with her retirement home personnel and decided she never would want CPR.  A do not resuscitate order was initiated by completing a POLST form (physician’s order for life-sustaining treatment).  She made copies of the POLST form giving them to her physician and retirement home staff.

While at the corner store, Agnes felt light headed and sat for a moment but then slumped to the floor.  Shoppers at the store immediately started CPR and 911 summoned the medics.  With the standard 1.5 to 2″ compressions of the sternum, multiple ribs were broken and the lungs were later found to be punctured.  Her heart rhythm was shockable and after 5 shocks, she stabilized and was taken to a nearby ICU.  The next few days were stormy both medically and ethically.  The hospital staff felt they had preserved a life, yet the family said she was ready to “pass on” and didn’t want the heroic life support.  Finally the family and POLST form wishes prevailed and she was “allowed” to die in the ICU after the tubes were removed.

Comment:  Society generally prohibits us from medically or surgically treating a patient without their informed consent.  However society places, quite naturally, a high value on preserving life.  Since the 1960′s CPR has been evolving and improving.  It has been popularized on multiple TV shows such as ER, where the survival rates approach 66%, much higher that the real word data (which continues to improve).

The frail elderly are a particular problem because the trauma of CPR may cause more harm than good in some individuals.  The statistics of young people don’t apply to the elderly.  And many elderly just don’t want CPR saying, “I’ve had a full life and having my heart stop wouldn’t be a bad way to go.”

Yet all of us are “signed up” for CPR, unless there’s a really clear way to avoid it.  Some families simply don’t call 911, some have POLST forms, or some spouses and caregivers are able intercept the process by demonstrating they have power of attorney for health care.

The American Bar Association has come up with a smart phone app to store advance directives and other medical data which might be helpful to the techie generation.  Some states have free registries and there is a fee based national registry for advance care documents, but finding these can be difficult in the acute situation.

The frustrating bottom line for the frail elderly is that very few of us have had an informed consent discussion about the pros and cons of CPR.  And even if we decide, “Heck, I’d never want anything like that,” a lot can still go wrong in terms of knowing and respecting our wishes.  Even a “no code” tattoo on your chest isn’t legally binding.  So in addition to having the conversation with your doctor and loved ones, try to come up with a plan if you really want to avoid CPR.  One thought is to electronically store any POLST/DNR orders with 911 responders.  That way, when they are summoned, the orders will be immediately available.   This may a concept worth field testing.

Jim deMaine is a pulmonary physician who blogs at End of Life – thoughts from an MD.

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