Case Presentation #1
Ms. R., an 83 year old woman living alone, is brought to the ER by her neighbor for evaluation of chest pain for the past 2 hours. Her son shows you a copy of a hospital discharge summary from 2 months ago, at which time she was admitted to rule out myocardial infarction. Her problem list is notable for a myocardial infarction 4 years ago, emphysema, a stroke 2 years ago, hypertension, and multiple infarct dementia. She presents alert and pale, with mild dyspnea. You are the ER physician, and as the nurse is taking her vital signs and putting on oxygen, she states that under no circumstances does she want to be revived if her heart stops. As the EKG machine is being connected, she says, "my heart stopped when I had my heart attack, and they brought me back, but I was on a breathing machine for 2 weeks. I'd rather die than go through that again. I've lived a good life, but it's getting hard for me to live at home, and I don't want to live in a nursing home!" She says that she has discussed this with her physician, but the paperwork is currently unavailable, and the physician cannot be reached. She has no available relatives.
Q: If Ms. R. has a cardiac arrest in the ER, should you comply with the patient's stated wishes?
Q: What other issues should be clarified with Ms. R. at this point?
Overall, the outcomes of CPR are less favorable in elderly people than in younger people, although the most important determinant of outcome appears to be the burden of associated illnesses rather than aging per se. For individuals with metastatic cancer, sepsis, and multi-organ failure, survival rates after CPR are close to zero. Rates of survival to hospital discharge after cardiac arrest are best for people who arrest in public places, whereas most studies have found that nursing home residents with serious chronic illnesses and functional disability rarely survive until hospital discharge. For both young and elderly adults, survival prospects are best if the arrest is witnessed and the presenting heart rhythm is ventricular fibrillation or ventricular tachycardia.
In general, CPR should be used when it is appropriate medical treatment. The determination of appropriateness requires judgment, and if patient autonomy is to be given a high priority, this determination requires that the patient be given adequate information on which to base a decision. In fact, many elderly people who initially express a desire to receive CPR in the event of cardiopulmonary arrest change their minds and do not want the procedure when a doctor explains the low probability of survival to hospital discharge.
The process of establishing an advance care directive should ideally begin prior to the anticipated need for a directive. The discussion between patient and physician should include an introduction of the topic (why it is important to perform this task); values (things that make life worth living or that would make life intolerable); a review of the patient's understanding of his medical condition, treatment options and prognosis; and establishment and documentation of preferences for specific treatments in the event of decisional incapacity, treatment outcomes, and quality of life issues. These preferences should then be communicated either in verbal or written form to provide the basis for future care decisions if needed. As part of the advance directive, patients may wish to designate a surrogate decisionmaker whose function would be to make decisions based on what the patient him or herself would have wanted. It is highly desirable for the patient and the surrogate decisionmaker to discuss preferences and values regarding medical care, in order to inform the surrogate's decisions. Without such information, both the patients' physicians and surrogate decisionmakers are inaccurate judges of patients' resuscitation preferences, even though surrogates are often the ones who make these decisions.
Open-ended questions that may help to facilitate discussions regarding these issues include the following:
Patients who appear to be decisionally incapacitated present a special challenge for clinicians. These situations are common in geriatrics practice, where patients are commonly delirious in the setting of acute illness or convalescence, where rates of dementia are high, and where problems such as aphasia and hearing loss may make accurate communication difficult. Criteria for determining decisional incapacity include:
From a practical point of view, the following approach to assessment of decisional capacity may be helpful:
1. Consider the relative benefits and burdens of the treatment being considered.
2. A decision to forego one therapy does not imply a decision to forego all therapies.
3. Demented patients are not necessarily decisionally incapacitated. Determination of decisional incapacity requires observation of an inability to make an informed decision at the time a decision is needed.
Ms. J. is a 85 year old woman who calls 911 for a complaint of severe, stabbing chest pain radiating to her back. On arrival, the emergency medical service (EMS) personnel find her to be pale, with clammy skin and blood pressure of 90/50. Pulse is 110 and respirations are 30. An IV is started, but the patient's blood pressure falls to 60/palp and the patient loses consciousness, followed by full cardiac arrest. EMS personnel note that the patient is wearing an "EMS-No CPR" bracelet, but her daughter who is present at the scene is very insistent that CPR be performed, and "everything be done" to bring her mother back.
Q: What should the EMS personnel do?
Q: Bonus question: Can you think of some possible explanations for Ms. J.'s sudden deterioration?
The EMS-No CPR program established for citizens of Washington State by the Washington State Department of Health provides a standardized approach to the pre-hospital management of emergency situations for patients who desire the option of EMS support but who do not want to be resuscitated in the event of cardiopulmonary arrest. This approach is protocol-based, and EMS personnel are under the guidance of a physician available by radio contact.
The cornerstone of this program is the Emergency Medical Services EMS-No CPR Directive and bracelet. The Directive indicates that CPR (including ventilatory support other than manually opening the airway, endotracheal intubation, chest compressions, cardiac monitoring, advanced airway management, defibrillation, and intravenous resuscitation medicines) is not to be performed, but that other measures intended to provide comfort care and to alleviate pain (such as intravenous fluids, oxygen and other therapies consistent with EMS protocols and scope of practice) are to be provided. The Directive should be obtained from the patient's primary care physician. It must be signed by the patient (or person with legal power of attorney for health care) in the presence of the physician, and must also be signed by the physician to be considered valid. Original copies of the Directive are to be maintained and displayed at the patient's home, and should accompany the person while traveling if the bracelet is not worn. Copies may be given to other health care providers, but only the original directive or the bracelet is honored by EMS personnel.
Who is eligible for the EMS-No CPR program?
This program applies to people 18 years of age or older who have decided they do not want CPR performed in the event that they suffer a cardiac or respiratory arrest. They do not need to have a physician diagnosis of a terminal condition. However, the EMS-No CPR directive must be signed by the individual's physician.
How do individuals obtain an EMS-No CPR Directive?
Directives and bracelets are available from physicians, local hospice organizations or hospitals. If the directives or bracelets cannot be obtained from any of the above, individuals should call the Office of Emergency Medical and Trauma Prevention at (800) 458-5281, extension 2, or (360) 705-6716.
Is this directive the only one EMS providers can accept?
Ideally, the EMS-No CPR Directive should be the only form or bracelet EMS personnel will need to look over. Standardized advance directives in the prehospital setting decrease the confusion over whether emergent care should be provided or whthheld. EMS personnel are permitted to honor other physician-originated Do Not Resuscitate (DNR) orders, after consultation with the physician managing the emergency.
Can the family override the EMS-No CPR directive by insisting that CPR be done?
If family members "vigorously or persistently" request EMS personnel to perform CPR, and these personnel are unable to get them to change their minds, established protocols direct EMS personnel to start CPR, then contact the physician managing the emergency for further guidance.
How is the public being informed of this program?
Information on the EMS-No CPR program has been share with radio, television and newspapers throughout Washington state. The Washington State Hospice Organization has also been asked for their assistance in providing information about this program.
Do EMS personnel need to see both the form and the bracelet in order to withhold CPR?
Either the bracelet or completed EMS-No CPR form can be honored. It is not necessary to see both.
If an EMS-No CPR patient has a medical emergency (such as choking) but is not in cardiac or respiratory arrest, should 9-1-1 be called?
Yes. The EMS-No CPR Program does not mean No Treatment or No Caring. Under this emergency scenario, EMS providers might be able to clear the airway obstruction and thereby relieve the pain and suffering associated with choking. After the airway is cleared, if the patient progresses into cardiopulmonary arrest, then further resuscitative measures would not be indicated.
Do these Guidelines apply to children?
Under the Natural Death Act, the Guidelines apply only to adult patients 18 years of age or older.
Can EMS personnel recognize other out-of-state DNR orders?
EMS personnel are permitted to honor other physician-signed DNR orders, after consultation with the physician managing the emergency.
How do EMS personnel decide if someone claiming to be a legal surrogate is telling the truth?
EMS personnel do not have to make this decision. If someone claims to be the legal surrogate for the patient, then EMS personnel can, on "good faith", take their word.
Click on the link below for a more detailed discussion of current EMS-No CPR Guidelines:
http://www.doh.wa.gov/hsqa/emtp/pub&rept.htm________________________________________________________________________
*Information for the FAQ section of this site is abstracted nearly verbatim from a brochure published by the Washington State Department of Health, Health Systems Quality Assurance Division, entitled "EMS-No CPR: Questions and Answers for EMS Personnel" (reproduced with permission). The remainder of the information on the EMS-No CPR program is based on additional information provided by the Washington State Department of Health, Health Systems Quality Assurance Division. Their assistance and cooperation in providing these valuable resources is gratefully acknowledged.
We are indebted to Robert A. Pearlman, M.D., for his advice and review of this section of the web site, and for his work in the area of advance care planning and assessment of decisionmaking capacity. His research in these areas forms the basis for much of the material presented herein.
Click here to go to the Web Site for the EMS-No CPR Workgroup of the Office of Emergency Medical and Trauma Prevention.
Click below to link to Home Page for University of Washington, Division of Gerontology and Geriatric Medicine
Copyright 1999, 2000 David A. Gruenewald, M.D. and Kayla I. Brodkin, M.D. All rights reserved.