The Hidden Harms of CPR

August 7, 2023 5:32 PM

A doctor writes about the trauma of CPR - both for the patient and the doctor - and how few patients actually benefit from CPR. “The bioethicist Nancy Jecker has written that “reflexively using CPR” suggests a fear of failure, of “losing the war we wage against disease.” Over the years, patients and families have told me that CPR represents a human right, a decision to go down fighting, a show of advocacy for their loved one, and a sign that everything possible has been tried. For doctors, too, it’s a ritual, a talisman of care. I’ve seen colleagues not offer surgery to patients who are too sick to survive an operation; kidney specialists will stop dialysis for patients whose hearts can’t handle the side effects. Yet these same physicians struggle to recommend against resuscitation, despite knowing that death is certain and near.”
posted by Bottlecap (37 comments total)

Incredible piece. Thank you.
posted by tiny frying pan at 6:09 PM on August 7, 2023 [1 favorite]

Terrific article. I was a beach lifeguard for nearly a decade and was lucky enough to have to perform CPR only once. It was a brutal nightmare, and it didn't work. I'll never forget the feeling of his sternum sperating from his rib cage under my palm, or the steady accumulation of bloody foam in his mouth, nose, and eventually the corners of his eyes.

I had talented, well-trained colleagues who'd done it a dozen times or more over the years and hadn't had a single patient survive. It's an incredible tool in a very narrow set of circumstances, but as the article suggests, in the vast majority of cases it's a violent, traumatic waste of effort.
posted by saladin at 6:20 PM on August 7, 2023 [39 favorites]

Personally, I never really minded coding someone where the result is a foregone conclusion. It's a relatively brief ritual, and they are dead at the start, so it's hard to argue that you've made them worse off. It is unlikely that there is discomfort, although I have had high quality compressions cause people to regain consciousness and fight, only to drop back unconscious when they were paused. It is a separable question from the drawn-out and futile ICU stay which does much more harm.
posted by a robot made out of meat at 6:30 PM on August 7, 2023 [16 favorites]

Ooof, that was a rough read -- but I am glad that first doctors and then patients are facing the facts (instead of making decisions based on TV shows).

I knew that CPR had a low rate of success but I had no idea it was so starkly useless for old, sick people. It's just violence for the sake of appearing to try.

I pity the doctors who have been forced to assault their weakest patients over the years. My son is entering the health care profession, and hearing stories that go directly against the kind of "mandatory heroics" he learn in things like the Boy Scouts Lifesaving merit badge.
posted by wenestvedt at 7:14 PM on August 7, 2023 [4 favorites]

I have had a beloved aunt successfully revived by CPR; her heart just stopped at a Unitarian-Universalist service one day, and one person in the congregation--one--knew CPR and brought her back. That was [does the math] 35 years ago, and she's still alive and healthy for a woman her age. I believe that her diagnosis was sudden arrhythmic death syndrome (SADS), where your heart just kind of up and stops one day for no apparent reason; in her case, the unnecessary procedure was the implantation of an internal defibrillator, which, it turns out, would never really have worked if she'd needed it, something they found out some time after the procedure. (I think that it's still inside of her because removing it wouldn't be worth the risk.)

That having been said, I totally get what the article is getting at. I really don't want someone making my last minutes or seconds full of pain and fear if the result is a foregone conclusion.
posted by Halloween Jack at 7:18 PM on August 7, 2023 [10 favorites]

Wow, I had no idea.

When my step-dad died, they did CPR despite him having a DNR. I'm not sure why. My aunt, who is a retired nurse, said it might have been because his heart stopped during a procedure. I think it was just sloppy. It was in a rural hospital that was struggling to care for him. We heard the code called and knew it had to be him. We then had to wait for a doctor to come tell us what was happening. He went through the whole explanation, which I understand he had to do, but my mom finally interrupted him and said, "are you asking if I want you to stop? I want you to stop."

We knew he wouldn't want it, but didn't realize it was so pointless.
posted by Mavri at 7:20 PM on August 7, 2023 [8 favorites]

If there were a piece of jewelry I could routinely wear that meant Do Not Do This Shit To Me, Not No Way Not No Day, I would buy it in a heartbeat.

If I'm going, let me damn well go. Ain't no shortage of people in this world.
posted by humbug at 7:48 PM on August 7, 2023 [11 favorites]

Interesting to hear how much the author desired communication training. I just finished nursing school and there was a major focus on communication. I've had test questions on how to compassionately and honestly explain to a family that a person is dying. (Usually the wrong answers were quite obvious, but the idea of practicing the language before you need it was definitely present.) We also practiced having difficult conversations with family members during simulations.

Of course, a big difference is that as nurses we do not have to work with the family to make the decision.
posted by Emmy Rae at 7:49 PM on August 7, 2023 [11 favorites]

Emmy Rae, you will absolutely work with families around those decisions. They will have questions that the doctors didn't answer or didn't have time for, they will ask your opinion on what you would do. It is, depending on where you work, a huge piece of the job. Those communication skills are critical.

(Congratulations on getting through nursing school!)
posted by Pantengliopoli at 8:02 PM on August 7, 2023 [13 favorites]

@Pantengliopoli yeah, that was poorly worded, I just meant that the doctor is the one officially getting patient consent for major stuff.

I am definitely familiar with facing a bunch of questions the moment the doctor leaves and the patient or family now feels they can ask all their questions to a person of less intimidating status.
posted by Emmy Rae at 8:05 PM on August 7, 2023 [11 favorites]

Still, less than ten per cent of people who receive CPR outside a hospital survive.

Not a huge fan of the presentation of an absolute stat for this - what’s the relative
improvement in survival over not doing CPR for an out-of-hospital cardiac arrest? A quick search gives me 2-3x, and that’s just survival, not considering reduced risk of brain damage and so on. So I don’t think CPR is ineffective, I think cardiac arrest is really bad.

But I completely sympathize with the point that there’s a big gap in communication about medical futility. It’s easiest when dealing with something like cancer, when there’s a process that will kill the patient eventually, but as the example of Andrew from the piece shows, even then it can be hard to get across.
posted by atoxyl at 8:20 PM on August 7, 2023 [14 favorites]

My first job out of college was working at the same company as Guy Knickerbocker, one of the co-discoverers of CPR. The story I heard is that CPR was discovered almost by accident. Knickerbocker was an engineer who specialized in defibrillators. One time, while he was working with doctors in a lab experiment to revive a dog that was in cardiac arrest, he noticed that the dog's heart restarted even before the electricity from the defibrillator reached the dog. That was the basic insight that led to the discovery of CPR.
posted by jonp72 at 9:05 PM on August 7, 2023 [3 favorites]

This article was extremely illuminating for me. I am 70 y/o and had a heart attack and triple bypass 8 years ago.

On Sunday I underwent a procedure called a nuclear stress test. This is a procedure in which a chemical is injected to approximate physical exercise to a certain level harder than your norm, and your vital signs are recorded, scans are taken etc.

I had taken this test several years before the actual heart attack and it was bloody awful. A medication called dobutamine was used and I thought I was gonna die, no exaggeration.

I was assured this time that a different medication was going to be used which had a less stressful effect on the body, and I accepted that and hoped that was true. And in fact it was true.

I was asked to sign a consent form prior to the 1st injection but who reads consent forms? I'm pretty intelligent but consent forms in general basically say if you die we're sorry (not quite) but you/your beneficiaries cannot hold us liable. I signed the consent form and then I nonchalantly asked the physician: is there a crash cart in this room?

He was disconcerted by the request. He said that there was one, and showed it to me, a piece of equipment over in the corner. At that point he seemed a little disturbed and started questioning me about whether or not I had a health care proxy/living will on file with the hospital. I informed him that I had filed one with my cardiologist and my PCP (hospital affiliated); and with some restrictions I had a DNR, a do not intubate, and palliative-care only instructions. Life has not been easy since the triple bypass surgery, its consequences and my many comorbid diseases. I'm not interested in prolonging life unnecessarily.

I would say we had a very frank and open conversation about my wishes. He also indicated that he had done hundreds/thousands of this procedure, and had only had 2 crashes.

Now I had my sternum cracked open and sutured back together during my bypass surgery, so the article's description of what CPR can do to your body was not unfamiliar to me.

But I had no idea CPR was so frequently unsuccessful, unless you are young, healthy and having an acute aberrant incident.

I have above my bed, and I carry in my wallet, a signed note that says: DNR, do not intubate, palliative care only. But I wonder now what a first responder would choose to do if they came upon me and I am not responsive.

I have some thinking and some legal counsel issues to attend to, I believe.

Thank you for the link to this article. Really, many thanks.
posted by alwayson_slightlyoff at 9:32 PM on August 7, 2023 [39 favorites]

The TV Tropes page "CPR, Pretty Clean, Reliable" is a good summary of one reason why there is such widespread misunderstanding. Particular credit to those titles where scenes involving CPR are played for their romantic connection.
posted by rongorongo at 11:23 PM on August 7, 2023 [4 favorites]

I asked a question on the green a few years ago about how to get *informed* consent for a DNR for a family member who was cognitively challenged and afraid of dying. The whole problem with the DNR construct is that it comes from a liability perspective and reads to the uninformed like "don't help me if I am dying". I really welcome the switch to the alternate phrase, A.N.D. for “allow natural death”. So much more humane. It was clear that my family member (with heart failure and advanced coronary artery disease) was not a candidate for successful CPR, but I was amazed at how poorly the reasons why were articulated—either completely vaguely or with alarming detail—by the doctors and nurses involved. The DNR itself, in tiny legal print, offers no help.

The author of this piece is correct in that it is a linguistic problem. I have worked in the disability field, where informed consent is a human rights issue, but people give up all too easily on what constitutes the "informed" part. You have to be able to answer the "what's the harm in trying?" question, speak to the fact that CPR is misunderstood, and this takes time and a careful choice of words and details.
posted by amusebuche at 12:05 AM on August 8, 2023 [8 favorites]

I was a beach lifeguard for nearly a decade and was lucky enough to have to perform CPR only once. It was a brutal nightmare, and it didn't work.
The article doesn't talk much about this first-responder type of CPR - except to point out that is has an even lower effectiveness rate than that seen in hospitals. The precise training that people are given in this area seems to be always getting revised - but I remember it with the acronym "DR ABC" - where you start off with "Danger" (is there still danger?), "Response (any response from the casualty?) - hence "DR - call the a doctor now" - and on to "Airway, Breathing, Circulation" - if there is a clear airway, but no breathing or circulation then you are going to be doing CPR until help arrives. It may be exhausting and horrifying, the casualty may be seriously injured by the action and they could already be dead even - but the alternative, at that stage, is to do nothing until help arrives - so CPR it is. I am not sure I see that situation changing.
posted by rongorongo at 1:54 AM on August 8, 2023 [3 favorites]

So, there have been multiple incidents in both the US and the UK where Disabled and/or Chronically Ill people who did NOT have any terminal illness and did NOT have a Do Not Resuscitate order in place

went in for routine surgery

and woke up from general anaesthetic to find out that a nurse/doctor had put a Do Not Resuscitate bracelet on their wrist while they were unconscious. :(
posted by chariot pulled by cassowaries at 2:27 AM on August 8, 2023 [8 favorites]

About 6 weeks ago, my FiL (75) keeled over while in an out of the way place. His wife commenced CPR, until someone ran and got the trained first aider from the building next door, who they knew had a portable defibrillator available. They kept him going until an air ambulance arrived and he was flown to a specialist unit. He had a bunch of damaged ribs but no sign of brain damage, he had some treatment and is resting at home now.
posted by biffa at 2:43 AM on August 8, 2023 [14 favorites]

A dozen years ago, a 65yr old very fit friend of mind had a surfing accident and ended up not breathing on the beach. His nearby friends noticed and began CPR. They pumped his chest for a good 35 minutes (that shit is tiring!) until the ambos took over.

He didn't survive. Broken neck.
But quite a few sick people gained a new kidney, liver, heart, lungs, yadda yadda, that day.
CPR isn't only for the fallen.
posted by Thella at 3:29 AM on August 8, 2023 [34 favorites]

I found this article interesting, and it raised many more questions for me. Thanks!

I agree, in my medical training performing CPR was in some ways ‘a grisly rite of passage’. Different involvement as a medical student and resident – whether focused only on spelling off for compressions or running the whole code – mostly resulted in different ways to experience something traumatic.

Luckily I had excellent communication training, and now teach doctor-patient relationship and communication skills sessions. I am optimistic that communication – at least in the medical schools I’ve taught in – is a focus.

However, medical training and the medical system remains discriminatory and especially ableist.

Rarely do we address how ‘healthy’ people are being defined, or how physicians are thinking about the patients they label ‘healthy’ , and in this article candidates for CPR. As chariot pulled by cassowaries’ comment indicates, a doctor’s determination of disability or chronic illness is often enough to label someone as ‘unhealthy’ or not-healthy-enough to be worthwhile caring for, absent this desire from the patient.

Physicians often decline so-called heroic measures, and the way they desire to die is often different than the way their patients have. However, I think this is less due to a better understanding, or informed consent of the process, and more due to being used having power and privilege within the system, and having confidence that their decisions will be respected. A doctor is more likely to trust they will still receive care even if they are labeled AND or DNR, whereas a patient with disabilities or chronic illness, used to being ignored within the system, knows they are already offered fewer options and understandably may not want to limit this further, nor trust in the process.

The intersection of my privilege and power as a doctor with identities that render me vulnerable and marginalised – namely disability – is striking. Even as I am a part of the system, as a physician, I do not trust it to be able to provide me adequate informed consent when the doctor on the other side sees me as less-than simply by virtue of my using a wheelchair, or who conceptualises disability as worse than death, and so already doesn’t think I should be living.
posted by narcissus_and_ambrosia at 5:46 AM on August 8, 2023 [28 favorites]

Most recent wilderness first aid course I took included CPR, as they always do. Instructor was pretty blunt: in effect saying “this rarely works, it never fixes things, but the goal is to prevent brain death before real help arrives” before going on to remind us that a defibrillator was the simple most effective way to help someone in cardiac arrest.

It was pretty different having the instructor tell us flatly that in the vast majority of times we might use the CPR we just learned, the person we were trying to help was going to die.

CPR is a last resort, not a solution.

(For that matter, the entire course was focused very much on how any attempt to help in the field was really a stopgap temporary thing to buy time, and a huge percentage of the training was not on first aid but rather on preventing the need for it in the first place. Same for the BSA first aid training I’ve participated in over the years as a youth and an adult volunteer. If you’re learning first aid as a general member of the public, and it only focuses on the after-injury actions, you’re not getting effective instruction. Unless you’re a first responder, your first aid focus should be on prevention of injury as much as it is on fixing it.)
posted by caution live frogs at 6:17 AM on August 8, 2023 [9 favorites]

In the first summer of the pandemic I ended up in the hospital. My back went out to the point where I couldn't walk, so I got an ambulance ride and a room for a few days while they checked things out.

I'd been hearing about what Covid patients went through when ventilated, and that's absolutely nightmarish to me. And I was very aware that being in a hospital was exposing me to Covid repeatedly, and I'm immunocompromised and have multiple comorbidities. So I made sure the medical staff was aware that I had a DNR/DNI order, and they wrote it on my whiteboard.

One day I was enjoying a marathon of Nicholas Ray movies on TCM when a doctor I had never seen blew into the room abruptly. He said hi, and he wanted to ask about the DNI order; he seemed weirded out by it. I told him that I knew it wasn't like on TV, that it was a brutal process that often left the patient debilitated or vegetative, and I wanted to skip it.

He raised his eyebrows, shrugged, said "Okay" and left.

I never saw that doctor again, but that visit has puzzled me ever since. Is it really so weird to plan ahead for being in a life-threatening situation? Is a DNI order so unusual that it warrants unaffiliated doctor visits? Is it that strange that someone makes decisions based on real-life medicine instead of what they saw on TV?

Anyway, it occurs to me that part of the process of normalizing the AND approach in appropriate situations is that doctors should probably get better at not being freaked out when their patients make rational decisions about their end of life health care. It's really not that weird to want to die rather than do the typical American end of life ritual.
posted by MrVisible at 6:47 AM on August 8, 2023 [5 favorites]

Great article, I just wished the post made it clear it's about CPR in certain cases in hospital scenarios.

Because if you stumble upon somebody who's in a situation of need there should be no hesitation to perform CPR, you don't have context or the information to make those kind of decisions and even though success is rare, it happens.

It struck me that the article described how doctors are reluctant to not provide this care. A few years ago we passed a law legalizing and putting a framework around medical assistance in dying, and there's been a lot of push back from some doctors or palliative care facilities. It just deeply unnatural to not be pushing back against death.

They pumped his chest for a good 35 minutes (that shit is tiring!)

I've been told that if you're not tired after giving CPR you're doing it wrong. And most movies/shows are not portraying this in a realistic manner (compressions not fast enough, not deep enough), and this is a disservice, it would be a great subconscious training for everybody.
posted by WaterAndPixels at 6:54 AM on August 8, 2023 [4 favorites]

My grandfather was lucky enough to die in the hospital he helped found, so he could be fairly sure of getting the care he wanted. He knew what was killing him, and exactly where he wanted the line drawn. My mother and my aunts sat with him at the very end. It was quiet and sad, but not traumatic. It was the first time I had actually seen death, and I can't imagine how horrible it would have been to come in frantic futile action (which would absolutely have involved a ventilator and CPR) instead of being able to say a gentle good-bye. Later a friend asked me if I felt guilty because we had respected his DNR and I was baffled. My grandfather knew his illness better than anyone not in his body, and he certainly had more medical training and experience than I did. Why wouldn't we trust that he had reasoned out the right decision for his situation?
posted by Karmakaze at 7:31 AM on August 8, 2023 [5 favorites]

Really good article; here is an article looking at the same issue from a medical journal. I have done CPR many times, and it has been successful in a large number of these times. But that is because I am in the area CPR was originally used for: the operating room and recovery room. Those patients not only have experienced a cardiac arrest that may be from an easily reversible cause, but it has been witnessed and treatment begun immediately. The rule of thumb is that survival decreases by about 10 percent for every minute without effective CPR, so any delay is costly.

The linguistic aspect is also important; that is why “Do Not Resucitate” is being replaced by “Allow Natural Death” in many places. DNR can convey the impression that the patient is being denied treatment; AND changes the emphasis to the fact that the patient is nearing the end of their life and that their medical care should reflect that. By sheer coincidence I am actually having a conversation with a friend of mine whose 80 year old mother with multiple medical problems is in the ICU on a ventilator. The ICU team just asked her if she wanted them to do CPR in the event of a cardiac arrest. She told them no CPR; I told her I thought that was a good decision.
posted by TedW at 8:33 AM on August 8, 2023 [8 favorites]

A good friend of my brother was recently one of the minority helped by outside of the hospital CPR...for a while. He had been diagnosed by ALS in the spring, and his progression was so fast by July 7th he was having breathing problems and his heart stopped. Some friends did CPR and medical teams got his heart restarted, although breathing was still difficult and he had to be put on BIPAP. About a week later it was clear that the ALS had progressed too much, and he made the decision to remove breathing support and passed away July 18th.

Even though the CPR wasn't a permanent fix and he was stuck lying without food and water for days, he said in the end "he wouldn't trade it for the world". He was the one who was able to make the decision to remove care. Family and friends were able to come and say goodbye. A call came out on social media for all to share stories, and he was able to experience how much he was loved before he left this earth.

In short, ALS sucks, end of life decisions are complicated, and I need to get my wishes down on paper and keep them updated.
posted by weathergal at 11:20 AM on August 8, 2023 [10 favorites]

I think the out-of-hospital point is mostly tangential to the core issue here - CPR is taught to the public and performed by default by first responders because it’s what you can do in an emergency that is often fatal no matter what, and considered against that low base rate of survival it does make a significant difference over not doing it. In-hospital it actually works better for a similar disease state, since you’re in the hospital, but it’s the last stop in a whole series of last ditch, brutal interventions that are often made on people whose chance of long-term survival is minimal. And that’s the part that all of us, as future patients, need to understand.
posted by atoxyl at 12:09 PM on August 8, 2023 [2 favorites]

I am reading this in a hospital as Mrs. Doctornemo recovers from a heart attack.
She has a DNR and... damn. I can't write more.
posted by doctornemo at 1:24 PM on August 8, 2023 [31 favorites]

When my step-dad died, they did CPR despite him having a DNR. I'm not sure why.

If you have DNR but it isn't signed, or the signature isn't in date, or it is not immediately available, full code is assumed.

Necklaces and tattoos will not count. You need the signed document in hand.

If you want your DNR to count make sure to have it signed, correctly dated, and leave it somewhere very obvious to family members and EMTs... clearly labeled on the fridge is a good choice.
posted by Ardnamurchan at 1:26 PM on August 8, 2023 [3 favorites]

This article made me curious about CPR "in the field" success rates vs hospital rates.

But yes, my CPR training included the bit that "even if they die you should keep pumping compressions until the ambulance takes the body away to avoid traumatizing onlookers" as we were not to be medically authorized to declare someone dead
posted by eustatic at 2:46 PM on August 8, 2023

If you want your DNR to count make sure to have it signed, correctly dated ...
The trauma associated with CPR and, more so, her fear of 'living' in a vegetative state was what led my Mother to have an Advance Care Directive in place for as long as I can remember. You don't need a lawyer - here in Australia, there are standard forms you can complete to put this in place. The standard forms do require a doctor to certify they have discussed the choices with the person making the directive. These are legally binding documents and must be followed.

Having it signed and dated is part of what's important, but it's also critical to make sure that it is seen to reflect your current wishes, not just something you filled in a decade ago and may or may not have since changed your mind. My Mother's plan had been reviewed every two years and re-signed and dated.

It's also important to carefully choose who you elect for any enduring power of attorney - my Mother had originally put all of her children in hers but, when she found out that one of my sisters would never agree to any action that might lead to her death, she took her off. Make sure you talk to the people involved and are sure they will follow your wishes. Make sure they have a copy or know where it's kept.

In the end (literally), having the directive in place meant my Sister and I didn't have to make the heart-breaking decision to end life-prolonging treatment, because the decision had already been made. We showed the directive to the doctor and, once they confirmed it was valid (particularly the issue of it reflecting her current wishes) and she was in one of the states described (end stages of a terminal illness from which she could never recover), the decision was made. She was made comfortable and pain-free and nothing else.

In an emergency situation, CPR is critical to get someone to a place where rational decisions can be made about future treatment and I encourage everyone to learn how to do it, because you never know when it could give someone a long and fulfilling life. But I wish it wasn't seen as some magical cure for all that ails you, because sometimes a person's time is up and the best thing you can do for them is let them go peacefully.
posted by dg at 3:25 PM on August 8, 2023 [3 favorites]

For a family member's death, we had a copy of the signed DNR document that hospice taped to the front door but the EMTs (who shouldn't have been called in the first place but that's another story) were pretty adamant that it had to be an original copy and went ahead and tried to resuscitate a clearly dying/dead person anyway. It was a really bewildering/bizarre moment of inflexible bureaucracy.
posted by flamk at 7:44 PM on August 8, 2023 [2 favorites]

For those interested in CPR, this classic post in the blue reveals a rabbit hole worth visiting: The most kissed girl in the world - (yes, by you too probably).
posted by rongorongo at 10:25 PM on August 8, 2023 [1 favorite]

Thanks for bringing the shocking DNR issues in the UK to my attention, chariot pulled by cassowaries. I wasn't able to find anything in the US, do you have links to share?

My elderly father-in-law, who had advanced dementia, was required to have his DNR suspended durin gallbladder surgery. The attitude of the surgeon was, basically, you can't make me let him die on the operating table. I was thinking, that's exactly what I want you to do! He's in very poor health, very confused and agitated most of the time, was very clear starting years before that he didn't want CPR.

But it has never made sense to me that "full code" is the default. In my CPR classes we were never taught to look for the bracelet or end-of-life wishes. I think in practice unless you have the form physically with you, and a caregiver to tell the paramedic explicitly that you actually mean it, they will do CPR.
posted by wnissen at 11:32 AM on August 9, 2023 [1 favorite]

My elderly father-in-law, who had advanced dementia, was required to have his DNR suspended durin gallbladder surgery. The attitude of the surgeon was, basically, you can't make me let him die on the operating table.

You don’t specify when or where this happened, but if it was anywhere in the United States within the last 25 years or so then the surgeon was in conflict with the stated positions of his own and other professional organizations, and possibly his own hospital policy. (That last link is particularly significant in that anesthesiologists were very involved in the development of CPR, and we routinely perform procedures such as endotracheal intubation that in other contexts would be considered part of resuscitation. The American Society of Anesthesiologists was one of the first professional societies to look into the ethics of DNR/AND orders in the OR back in the early 1990s.) Unfortunately the idea that DNR/AND orders are “automatically suspended” in the OR continues to persist, even among people who should know better. The more difficult, but ethically appropriate, approach is for all the physicians involved and the patient and/or surrogate decision makers to discuss the situation in detail and decide how to proceed. Often the patient/family are willing to suspend the order, but even so, it needs to be precisely defined when it is suspended and when it is reinstated. Another option is to agree to some components of resuscitation, but not others. Generally this approach to CPR is frowned upon, but since some components of CPR may be part of the anesthetic plan for the patient it might be reasonable in this scenario. A third option is to leave the order in place, but leave it up to the OR team as to how best serve the patient’s wishes. Needless to say, these conversations can get quite emotional and take some time, but in my experience they generally go very well and all the parties involved can come to agreement on a plan pretty quickly. Patients and families tend to be very appreciative that their wishes are being respected. And having the conversation in advance is far preferable to waiting until an emergency happens and and someone has to explain to the family that their loved one is getting CPR despite their wishes and what do we do next?

Obviously this can get complicated and has been discussed a good bit in the medical literature. Good articles discussing the history, ethics, and practices concerning DNR/AND orders in the operating room can be found here, here, here, and here.
posted by TedW at 11:14 AM on August 10, 2023 [6 favorites]

TedW, those ethical guidelines for anesthesia with DNR are really interesting. For the record, this was in California two years ago and while I was involved firsthand in the discussion (both of the original DNR/POLST, and with the surgeon), I was not the medical power of attorney.

If you're operating on someone, it's presumably because you and the patient (or their representative) think that the patient's life will be better after the operation. But if the patient then codes during the procedure, the anethesiologist is in a weird position. On the one hand, they deliberately caused the patient to lose consciousness (and hopefully also sensation). On the other hand, their one job afterwards is to reverse the anethesia and bring the patient back to consciousness, at least under normal circumstances. I can see how that would be extremely difficult to let a patient remain unconscious and die.

The use of feeding tubes, though, is something that really needs to be exposed. Nothing I have found says that people who are terminal live any longer with a feeding tube. And yet it's right there on the form for "Life-Sustaining Treatment". Reasonable people can disagree on what constitutes acceptable quality of life after resuscitation, but the surgical insertion and care for a feeding tube, for no benefit, seems like torture to me. Some people feel everything should be done, and a feeding tube is definitely doing something. Note that I'm not talking about feeding tubes for people who benefit from them, just for people who would be considering a DNR.
posted by wnissen at 4:13 PM on August 10, 2023 [1 favorite]

The advance care directive template I linked earlier specifically includes artificial feeding as something to designate whether you want it or not. I understand some people have a perception of starving to death as a 'terrible way to go' even though they are hardly likely to notice if they are actually in that situation.

When we discussed what do to for my Mother with the doctors, they said nothing they could do would extend her life, but they could do lots of things that would make her death much more protracted. They were very supportive of and agreeable with the 'give me all the drugs needed to make me not feel pain and nothing else, even if it hastens my death' instructions my Mother had left.
posted by dg at 4:23 PM on August 10, 2023 [1 favorite]