Do Not Resuscitate: Can saving a life do more harm to the patient than good?

The report also recommended improvements in Advance (Anticipatory) Care Planning, something that Health Improvement Scotland (the CQC’s counterpart here) has already energetically pursued.

But drill down, and we find that the lava comes from deep inside the core of modern medicine. The issues are far bigger than informed consent.

The first includes questions about cardiopulmonary resuscitation (CPR) that are rarely unpacked: when is CPR appropriate, when will it be successful in saving a life but, more likely, when is it going to fail? Public understanding is often lacking.

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CPR emerged in the 1960s. At the time it was the ultimate in death-defying treatments – thanks to the invention of the ventilator and the defibrillator.

The prestige has never waned. We donate to local charities that provide defibrillators in cinemas and golf clubs. Do-it-yourself resuscitation is a community goal.

My own experience of CPR ranges from the exhilarating to the tragic. I was a junior doctor in the late 1970s in a rural hospital in Ireland.

One night at 4am in the newly opened coronary care unit, a 48-year-old farmer with a recent heart attack was successfully resuscitated. It was a triumph.

Even better, the triumph morphed into joy when, 10 hours later, he got married. He had been engaged for 19 years to the similarly aged daughter of the neighbouring farm.

Both had ageing parents and the demands of farming meant that their marriage had been repeatedly postponed. A hasty ceremony was needed lest another cardiac event prove fatal.

Successes can skew our perspective. The realities about CPR are much less exciting. Cardiac rhythm disturbances or obstructed breathing threaten sudden death and are reversible with CPR. But these mechanisms are an uncommon cause of death.

For most of us, death is a process rather than an event. Degenerating organs or disseminated malignancy or advancing frailty are the usual precursors of mortality. The end-point for each is that heart and lung function cease. A natural death occurs.

Especially during the 1980s and 1990s, CPR was increasingly used even when death could have been anticipated. The possibility of dying was ignored. Death represented failure. A series of protocols was entrenched with CPR as a standard of care.

As recently as 2015, a Gateshead nurse was found guilty of professional misconduct for not undertaking CPR on a patient “who had a life-limiting condition and was fed through a tube”. The story was repeated in South Tyneside in 2017.

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These events highlight the most bizarre dimension of CPR that drives policies and practices. Uniquely, CPR is the only medical treatment that requires a patient’s consent for it not to be done.

CPR on TV often ends well: the success rate is around 70 per cent. In real life about 50% of patients survive after CPR if the “arrest” is unexpected and due to a reversible cause.

However, all-comer analysis indicates much lower success rates. After initial resuscitation, many die within a few days. Survival to discharge from hospital averages about 18%.

Recently it has been claimed that older people were being discriminated against because of their age. It is not age but frailty that is critical: survival after CPR is zero in patients with moderate to severe frailty.

CPR is routinely taught as part of first aid training

Caught between medico-legal imperatives and poor outcomes, the absence of a DNR often creates anxiety for health professionals, lest they have to undertake a futile CPR attempt.

The survival statistics are not the only issue. It’s the grotesque cruelty of CPR, especially if the person is someone for whom dying ought to be honoured with dignity and kindness.

Doctors vote with their feet. A recent survey revealed that almost 90% would never consent to CPR: I am among them. I have participated too often in CPR attempts that have delivered needless prolonging of the dying process.

The second layer goes even deeper. It was the anthropologist Ernest Becker who proposed that most human activity is subliminally energised by the survival instinct.

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Deconstruction of Western societal belief in the afterlife has coincided with huge advances in medical science. Together, these have raised expectations concerning medical treatments but paradoxically intensified the fear of non-survival.

Organ transplantation, unblocking arteries in the heart, cures for certain cancers, and now the development of Covid-19 vaccines – these all testify to the victories of medicine over disease.

CPR was the earliest of the successes. But, as Atul Gawande pointed out in his book 'Being Mortal', the triumphs are temporary. Death always has the last word.

To say so remains taboo. Societal passion for denying and defying mortality motivates the anxiety around what the CQC highlighted.

The issue is greater than the failings of professionals who sidestepped ethical processes. It is that CPR is potentially life-saving and everyone deserves life-saving treatment all of the time. Who dares to argue against that?

Thus, for some, CPR has the status of being a human right. I disagree. I have a right to have my life protected but not indefinitely extended, especially if attempting to do so causes harm without much hope of success.

Primum non nocere (first, do no harm) is a valid ethical responsibility. To believe that CPR may be futile or harmful, or both, does not amount to discrimination. But it does need sensitive discussion.

Most people who die in the UK follow an end-of-life trajectory characterised by progressive physical or mental decline – due to frailty, organ failure or relapsed malignancy.

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It is not wrong to think that when things are truly uncertain, every effort should be made to restore a patient back to health. But too often clinicians as well as patients focus exclusively on short-term outcomes. “Do everything possible” and “give the patient the benefit of the doubt” are often stated.

“Last chance medicine” is alive and well in our hospitals. It is often the default response when treating a sick patient. Risk aversion drives junior doctors’ behaviours: safer to intervene and ask questions later.

Advocates take the moral high ground despite some appalling outcomes: “We were only doing our best”.

That statement is true if the potential for harms is ignored. But when a patient’s health is irreversibly declining, major medical interventions are more likely to deliver harms than temporary benefits. CPR is in this category.

Patient with 'do not resuscitate' wristband

Before the “fix it” approach is launched in response to an emergency, questions need to be asked. What are the best-case and worst-case scenarios if treatment is or is not given? What are the patient’s perspectives and preferences? When is letting go more appropriate than clinging on?

Patients offer a range of responses when these things are openly discussed and they should be heard.

At the outset of the pandemic, survival at all costs was the political goal. That led to unintended consequences that we have yet to debate. We were unprepared for the scale of the emergency in 2020 and its impact on the NHS.

But we were also unprepared for the ethical tensions and complex dilemmas that we faced. Policies were hatched on the hoof. Open discussion about triage was deliberately blocked in high places as too hot to handle.

In truth, as for DNR, we were caught out because issues concerning death, dying and the role of modern medicine have been suppressed.

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In 1984, in St Paul’s Hospital, Vancouver, I was on call in the intensive care unit. A 70-year-old lady was transferred from the operating theatre where she had had a cardiac arrest.

fact, she arrested four times in six hours and I helped to resuscitate her each time. There was no DNR: the surgeon had insisted that attempts at CPR should continue. Each time she regained consciousness, she was agitated, unable to communicate.

I called her family in. Before long they signalled to me that neither she nor they wanted another CPR attempt. Her breathing tube was removed and for an hour she was able to speak with her husband and adult children. Then she died peacefully.

With memorable anxiety, I wrote four pages of notes justifying my actions. Why did it need to be that way?

I hope that the experiences of the last year will open the door, not to endless blame and criticism, but to truthful open discussion. It’s time for a better way.

Dr Robin Taylor is a consultant respiratory physician and author of Coping With Crisis: Navigating The Challenges Of Medical Decision-Making In Critical Illness. This article is a personal perspective.