Last Wednesday, we published a blog about the POLST/MOLST form (please click to read), a topic that came about following a presentation on Advance Directives by certified elder law Attorney RJ Connelly III, to a group of seniors at an assisted living facility in Providence, Rhode Island. During the presentation, a handful of seniors expressed some disagreement on what the POLST/MOLST form was designed for and how it should be used for those in the home, which included assisted living and long-term care facilities. "Talking about end-of-life options is always an uncomfortable discussion to have but a necessary one given the graying of America," said Attorney Connelly.
The seniors raised many questions about the use of the form, which Attorney Connelly attempted to explain by using the words of the National POLST organization, but they continued to disagree with the premise. A few even stated that a POLST/MOLST form should not be used because "everyone deserves CPR no matter what because it works." Attorney Connelly, in response, pointed out that CPR (Cardiopulmonary Resuscitation) is not a magical treatment, unsuccessful in most cases when the heart itself has received major damage or the patient has a terminal condition, and the result of using the procedure on older bodies can be quite traumatic and lead to additional internal injuries and broken bones, consequences that need to be considered when choosing to receive CPR.
Shortly after this presentation, Dr. Liz O'Riordan, an oncoplastic surgeon (oncoplastic breast surgery combines the techniques of traditional breast cancer surgery with the cosmetic advantages of plastic surgery), authored an article for the English newspaper, The Daily Mail, about the importance of having advance directives and the inconvenient truth about CPR, and we wanted to share this with you. But before we get to her article, a little about the doctor herself.
A Doctor and a Patient
Dr. O'Riordan knows all too well of what she writes, being diagnosed with Stage 3 breast cancer in 2015 at the age of forty and having it return just three years later and again successfully treated. Because of what she experienced as both a doctor and a patient, she started an award-winning blog about her experiences which led to her lecturing internationally about how to improve the quality of patient care.
Although she is now retired from her medical practice, she continues to work part-time as a public health consultant reviewing the notes of patients who have died in the hospital trying to find ways to improve the care of dying patients. She has also set up an international WhatsApp group for doctors with cancer to share their unique experiences of being on both sides of the table.
"Given her history and her work, she approaches this subject with a unique perspective and knowledge that everyone should listen to before making a decision about end-of-life measures," said Attorney Connelly. "Hopefully, this article can give some insight into why the MOLST form exists." Now, here's Dr. O'Riordan's article as it appeared in The Daily Mail.
Heroic Measures Are for TV Shows
The first time I saw CPR being performed was on TV. I was in my teens – it was probably the American medical drama ER. Maybe it was Casualty. There would always be a frantic scene of a medic pumping away at a patient whose heart had stopped. Someone would rush in with defibrillator paddles. Someone else would yell 'CLEAR!' For a moment, all hope seemed lost and then the body would jolt back to life. Relief all around. The patient was up and talking, or perhaps even heading home, before the credits rolled. It was gripping, dramatic and glamorous.
Years later, as a fledgling doctor working on a crash team on hospital wards, I got to see it and do it for real – and it couldn't have been more different. CPR, or cardiopulmonary resuscitation as it's formally known, is brutal and undignified. It's given when the heart stops – so in effect the patient has died – in the hope that it will bring them back to life. But it almost never works, because it is generally carried out on patients who are the sickest and the frailest in the hospital.
"Rib fractures are incredibly common...you can hear the bones break. If the patient's heart does start beating, they may be left with bruised or bleeding lungs. And damage to the brain and kidneys is not uncommon..." ---Dr. Liz O'Riordan
Their clothes are pulled off so the crash team can get paddles on their chest, and there are medical staff everywhere. Some are feeling for a pulse, others are cleaning up blood and vomit. It is noisy. Someone is shouting out the number of chest compressions, doctors grunt as they press down. Rib fractures are incredibly common because of the force needed to start the heart – you can hear the bones break. If a patient's heart does start beating, they may be left with bruised or bleeding lungs. And damage to the brain and kidneys is not uncommon – because of the time spent without the heart pumping blood around the body.
CPR if Successful, Has Drawbacks
In eighty per cent of cases where CPR is successful, the patient never leaves hospital.
Two-thirds of them die within a few days. About two per cent are left in a long-term vegetative state – neither dead, nor truly alive.
The one time I did bring someone back, when I was working in [the Emergency Room], the man was in intensive care for two weeks. Then we realized he would never recover and had to turn off the ventilator. It was horrible for his family. Later, as a surgeon specializing in breast cancer, I had to discuss all this with patients. Whether we want to be resuscitated if our heart stops is a routine question doctors ask when they admit someone.
"In eighty percent of the cases where CPR is successful, the patient never leaves the hospital. Two-thirds of them die within a few days. About two percent are left in a long-term vegetative state -- neither dead, nor truly alive." --- Dr. O'Riordan
It can feel alarming. But it's important, if someone is particularly ill and not going to get better – with late-stage cancer, for instance – that they understand if their heart stops, CPR really will just delay the inevitable, at best.
More recently, I've had to face up to my own potential death, after being diagnosed with breast cancer twice – for the first time in 2015, when I was forty, and then again three years later. Thankfully, my treatment was a success. But the experience spurred me into making some decisions about how I'd like my life to end. It wasn't easy.
No woman wants to talk to her husband about how she might die before him. But it's vital we make our wishes known. In particular, I have made it clear that if I reach the end of my life – if my cancer comes back and my heart stops beating – then I don't want CPR.
Making My Choices
Of course, if I had a sudden heart attack out in the street tomorrow – while I'm fit and healthy – and a defibrillator was close by, then I would absolutely want someone to try it on me. But that's because I'd actually have a chance of recovering. The chances are, if I'm very unwell – whether I'm being cared for at home or in hospital – that even if CPR did restart my heart, I'd be in a worse state. And that's not how I want to die.
I'd like to be in bed surrounded by my family, not a team of doctors trying to bring me back to life. It doesn't mean I won't receive treatment. Far from it. But I just want medical care to make me as comfortable as possible at the end. Of course, there will be those with long-term health conditions who think the opposite. They might say, 'I want to be given a chance no matter what.' But that needs to be a decision that's made after considering the facts. And I'm all for that. No one can tell you what to choose.
For a person in full health, whose heart stops unexpectedly, CPR, if given within minutes, offers a ten to twenty percent chance of survival. There is still a significant risk of long-term damage, but the benefits far outweigh this. If a person has serious long-term health problems, and their heart stops unexpectedly, CPR has a smaller chance of success – the heart may restart, but the body is unlikely to recover. And if a person has a terminal illness, if they are dying, and if there's significant damage to the lungs, liver, and kidneys, CPR is futile, in my opinion.
"If a person has serious long-term health problems...CPR has a smaller chance of success -- the heart may restart, but the body is unlikely to recover." --- Dr. O'Riordan
Restarting the heart cannot repair the damage already done by the illness. Of course, like anyone, I was horrified to read of 'Do not resuscitate' orders being written on medical files of elderly people in care homes during the pandemic, without prior discussion. And I have heard of cases where doctors have explained things badly and have caused distress. Not all doctors have an excellent bedside manner.
Use a MOLST and Living Will
In the hospital, if you are too sick to tell someone what you want, a senior doctor may decide not to administer CPR if it would do more harm than good – and loved ones can find this difficult without careful conversations beforehand. If you have a relative who's been admitted, and is very [sick], it's worth raising the subject. If the wish is to have CPR doctors will try to honor that.
And if, having thought about this, you think that you might not want to be resuscitated in some circumstances, then there are steps you can take to make sure people know.
If you are already under the care of a medical team, discuss your wishes with them.
There is a form your doctor will fill in to keep in your medical notes called [in the United States, the POLST/MOLST form]. This doesn't mean you won't get treatment – but if your heart stops, there will be no attempt to restart it (there are other choices on the form as well, read last Wednesday's blog).
If you want to make sure your relatives know your wishes, you can create a living will that lets you refuse medical treatment. It can be altered. It's only used if you're unable to communicate. It's another way to ensure people close to you know your wishes. I made a living will. It wasn't pleasant. But I'm content to know I will be spared CPR – and have the death I want.
Dr. O'Riordan gives us a lot to think about when it comes to the use of CPR in older adults. As we close out this blog, here are two facts to remember about the use and success of CPR.
Research shows that only ten to twenty percent of all people who get CPR will survive and recover enough to leave the hospital.
For the chronically ill, only five percent of those who are resuscitated by CPR live long enough to leave the hospital and, in those cases, most have difficulty recovering from the damage caused by CPR.
"Dr. O'Riordan's article points out some hard truths about CPR in seniors and those who are frail or have a terminal illness," said Attorney Connelly. "Research shows that besides the physical trauma that occurs, patients who receive CPR also have to deal with serious long-term consequences like possible brain damage from oxygen deprivation, which is much more of an issue for an older individual."
"The reality is that older bodies are physically weaker and therefore less likely to recover from the CPR procedure itself," continued Attorney Connelly. "And as the doctor pointed out, the existing health conditions that caused the heart to fail makes it even less likely that they’ll recover at all or have a decent quality of life afterward. This leads to the argument that using CPR on seniors leads to an unnecessarily prolonged and painful death. As hard as this is to discuss, these are things that individuals and families must consider when a loved one has a serious chronic or life-threatening illness, and as Dr. O'Riordan said, having the death they want."