People have always imagined the possibility of resuscitation. Greek and Roman mythology from over 2000 years ago describe Asklepios, who had the ability to bring life to those who have already died. Since then, people have been attempting resuscitation by means of elixirs, incantations, magic, and other various methods that would not be condoned by modern Western medicine. The first documented case of successful resuscitation by means of closed-chest compressions was performed on a cat by R. Boehm, a German pharmacologist in the 1870's. In the 1880's and 1890's, two German scientists, Koenig and Maass, documented several cases where a similar technique was used to revive several patients from cardiac arrest resulting from anesthesia (Basta 2001:82).
In the late 1950's, scientists at Johns Hopkins University developed methods of performing mouth-to-mouth artificial ventilation along with chest compressions. This finalized method of resuscitation became known as CPR (cardiopulmonary resuscitation), and became a widely accepted medical practice by the mid 1960's. Initially, CPR was only performed in hospitals, and mainly on patients who had gone into cardiac arrest due to anesthesia, or from electrocution (Basta 2001:82). However, as EMS (emergency medical services) emerged in the 1970's, CPR could be performed outside of hospitals, by trained paramedics and emergency medical technicians (EMTs). Around the same time, the American Heart Association standardized training for CPR, which allowed people without any other medical training to become certified to perform CPR (Collins 2005).
In modern day Western society, it is a well known fact that resuscitation is possible through the use of CPR. However, the public often has an unrealistic view on the success of CPR. Popular television shows often depict medical cases in which the patient goes into cardiac arrest. In these shows, about 70 percent of patients are resuscitated through the use of CPR. In reality, an average of only about 5 percent of patients have a self-generated heart rhythm restored by cardiopulmonary resuscitation, while it is estimated that only 1 to 3 percent live to be discharged from the hospital (Timmermans 1999: 4). Since the media has such a profound effect on modern day Western society, this depiction of high CPR success rates causes the public to have overly confident views towards CPR.
When producers of these television shows were confronted about their misleading representations, they stated that the public would be more likely to learn CPR themselves if they believed that it had a high success rate (Collins 2005:150). This may be true, but misleading the public to believe CPR has a high success rate can create many other issues. For example, by portraying CPR as having a high success rate, the media has affected Western society's view on death itself. False confidence in CPR leads to the belief that death no longer has finality, but is an easily reversible condition. This belief can easily lead to negative consequences for the patient and their loved ones.
There are many complications that can occur when a patient is successfully resuscitated by CPR. Especially in out-of-hospital situations, CPR is rarely initiated on a patient immediately after going into cardiopulmonary arrest. Since the patient is not breathing spontaneously, there is no oxygen being delivered to the brain, so brain cells begin to die. As the time before CPR begins on a patient is prolonged, the risk of permanent brain damage increases (Karim 1998). Also, there is the possibility that the resuscitated patient will be dependent on life support such as an artificial respirator. These are facts that are not taught in a typical CPR class, nor depicted in most of the media's portrayals of CPR.
In a society where death is viewed as an easily reversible condition, there forms a large grey area between saving a life and simply prolonging death. This creates the much discussed issue as to when resuscitation should be attempted, and when it is in the best interest for the patient to allow death to take its course. Many medical professionals believe that the patient's quality of life after resuscitation should be considered (Orlowski 1999). If a patient is living a life full of suffering, with no hope for relief, it is in the best interest of the patient to allow their suffering to be relieved by letting death take its course. In an instance such as this, resuscitation of the patient would only prolong their suffering.
Some people would prefer to have a sudden death in the security of their home, instead of prolonging the process of death through medical interventions. However, in today's society, most deaths occur in hospitals. Since CPR is believed to have a high success rate, death is not viewed as officially occurring when the heart stops beating, but not until a doctor officially declares a person as deceased. This leads to a decrease in the rate at which people have a "peaceful death," since official death is prolonged by CPR until the patient gets to a hospital. This is not in the best interest for the patient, and creates issues on the dignity of death (Timmermans 1999).
For those who would like to ensure that they are allowed to die peacefully, a DNR (do not resuscitate) order can be placed by the person. These are also implemented to those who would have a lower quality of life after resuscitation. To obtain a DNR, a person could fill out forms from various healthcare organizations, other organizations, or even create a self-generated request with a signature. However, the only DNR that should be legally honored in a pre-hospital situation is the one state-approved DNR (Orlowski 1999). Emergency medical crews are trained to continue resuscitation if there is any doubt at all as to the authenticity of a DNR, since every second could mean the difference between life and death. Since every second is critical in an emergency situation, emergency crews often do not have time to read through lengthy paperwork to confirm whether or not a DNR is authentic. Therefore, emergency crews will often perform CPR on a patient regardless of the fact that they have a DNR. Once again, this is another occurrence which is not in the best interest of the patient.
Emergency medical crews should not be blamed for performing CPR on patients with a DNR order, the faulty system of DNR orders itself should be blamed. Even if the patient were to have the specific state-approved DNR, many people who receive these do not realize that they expire after a year. Also, if a patient were to go into cardiac arrest while not with a loved one, there would be nobody to even inform emergency medical crews that the patient has a DNR order. Occasionally, a patient with a DNR will go into cardiac arrest, but family members will withhold the DNR from emergency crews, in hopes that their loved one will be revived. In the end, a DNR order provides little or no assurance that a person's wishes will be honored.
Another controversial topic involves the resuscitation of the elderly. Some believe there should be restrictions for the resuscitation of the elderly. The American Heart Association stated "When people reach the end of life, continued resuscitative efforts are inappropriate, futile, undignified, and demeaning to both the patient and rescuers" (cited in Orlowski 1999). However, determining whether or not a person has "reached the end of life" is a fairly subjective decision. There are many factors which can contribute to whether or not a person has reached the end of life. The patient themselves should be able to make the final decision as to whether or not CPR is administered. However, in the event that a DNR order does not exist, it becomes unclear what should affect whether or not CPR is ethical.
In the absence of a DNR, the next appropriate decision maker as to whether or not to attempt resuscitation would appear to be their family members. However, in present Western society, there are many factors which can cloud a family member's judgment when deciding what is best for their dying loved one. People do not often witness the occurrence of death, since present medical interventions allow people to live longer than ever. Since death occurs so rarely in Western society, people do not know what to expect when confronted with it in a real life situation. In addition, the media has caused Western society to deny death, by falsely imposing the belief that it can be easily reversed. The combination of the two causes people to no longer view death as a reality, but as an abstract thought. Therefore, it is hard for people to accept the fact that death is imminent for their loved ones. These factors create false hope for the revival of a loved one by means of CPR, which may or may not be of best interest to the patient.
When considering whether or not it is appropriate to perform CPR on the elderly, their dignity should be considered (Orlowski 1999). The process of performing CPR on a patient is very invasive, and can be very emotional for family members to observe. This can greatly affect the family member's views towards the act of CPR, and can cause their opinion to either support or oppose CPR, depending on the circumstances. Many times in Western society, a person's idea of death is what they have encountered at funerals, since this may be their only experience with death. At a typical funeral, a loved one's body is being honored and respected. This is in strong contrast to what a person may observe while watching CPR performed on a loved one. Many people in Western society would view the invasive procedures of CPR to be very demeaning and disrespectful to their loved one's body, which could cause them to want the procedure ended. Again, this may or may not be in the best interest for the patient.
The following are two real life scenarios I have encountered, in which family members had very different reactions to the attempted resuscitation of their loved ones through CPR. Through these true stories, it can be seen why it would be difficult for family members to decide whether or not CPR should proceed, while thinking of what is best for their dying loved one:
First Responders arrive at a room in a nursing home and find an elderly man lying unresponsive in his bed. After examination of the patient, it is found that the patient does not have a pulse. Paramedics arrive, and all necessary procedures for cardiac arrest are performed.
First, the man's shirt is cut off for better access to the chest where leads are placed for an EKG. The paramedic requests for chest compressions to pause, giving him a chance to view the heart's current spontaneous rhythm. After determining that the rhythm cannot be treated by an electric shock, chest compressions continue.
While chest compressions are occurring, the paramedic begins to intubate the patient. This involves the insertion of a long tube down the patient's throat and directly into the trachea. Artificial ventilation is then used to supply oxygen through the tube directly to the patient's lungs.
The paramedic then begins to establish an IO in the patient's right leg. An IO is a method of supplying fluids similar to an IV, only it is established by drilling into the patient's bone. After the IO is established, the paramedic begins to administer the appropriate medications. Throughout this time, chest compressions and artificial ventilation continue.
The emergency crew begins to move the patient from his room back to the ambulance on the stretcher, while an EMT stands on a beam at the bottom of the stretcher and rides it down the hall while performing chest compressions. Suddenly, a woman runs up to the stretcher yelling that she is the patient's daughter. The woman gasps at the sight of her father, and cries, "Stop! Please, stopâ€¦ He wouldn't want this. Please just let him go peacefully." The woman then proceeded to stop the chest compressions by pushing the EMT's hands off of her father.
The EMS crew tried to explain to the woman that they could not legally stop performing CPR without evidence of a valid DNR order, but it was clear that there was no way to change her mind. The woman was hysterically pleading the EMS crew to let her father pass peacefully, while continuing to push the EMT's hands off the man's chest. Just as the woman was pushing away the EMT's hands, the paramedic saw what he thought may be a spontaneous pulse on the EKG. The paramedic checked the patient's carotid artery for a manual pulse, and announced that a pulse was present.
Artificial respirations were still necessary while the patient was transported to the nearest hospital via ambulance. Upon arrival at the hospital, the patient was stabilized and put on life support. The patient required a mechanical ventilator to breath for the week he stayed in the hospital before he passed away.
There are many reasons why the daughter in this scenario would want CPR to be discontinued. The average person in Western society would be horrified at seeing their loved one getting their chest pounded, an IO drilled into their shin bone, an intubation tube inserted down their throat. The daughter's concern for her father's dignity was most likely one of the main reasons she opposed CPR. She would have much rather had her father pass peacefully instead of being demeaned through the process of CPR. The woman was probably right in her judgment that the administration of CPR was futile, since there was little or not chance for the man to live with sufficient quality of life after resuscitation. Unfortunately, with current protocols that are in place, the EMS crew was required to administer CPR in the absence of a DNR order.
This second scenario represents family members who portrayed very different reactions to the sudden death of a loved one:
First Responders arrive at the house of an elderly married couple, where the husband is complaining of moderate chest pain around a 6 or 7 out of 10. The man appears to be in some discomfort, but the pain does not appear to be unbearable. The man's wife states that she did not want to take any chances, so she called an ambulance. The man has little or no past cardiac history, and seems to be in good health.
While an ambulance and paramedics are on their way, the first responders take the man's vitals and follow all of their chest-pain protocol procedures. All the while, the firefighters engage in polite conversation, and begin to grow fond of the friendly elderly couple. It becomes clear that the husband and wife are very important to one another.
Suddenly, the husband stops talking, takes one last gasping breath, and stops breathing. The EMT nearest to him finds that he has no pulse, and yells for somebody to get the suction unit (a device used to prevent the patient's vomit from becoming an airway obstruction). The crew immediately initiates CPR, and tells the ambulance to upgrade their response.
When paramedics arrive, they performed all of the same procedures as in the previous situation. Nearly the entire time, the man's wife was still in the room, or within observing distance. However, in contrast to the daughter in the first situation, the man's wife wanted nothing more than for her husband to be resuscitated.
After a while, a group of about 7 family members (including a child) are at the house, all very worried about their father/grandfather. The family stayed in a different room, out of eye sight of the EMS crew working on the man. As an EMT passed the family to get some equipment, the worried family pleads the EMT to "please save Grandpa."
However, even as CPR efforts continued in the back of the ambulance during transport to the hospital, the man was not resuscitated. The man was pronounced dead by a physician at the nearest hospital, shortly after his arrival to the emergency room.
The men in both of these situations were around the same age, and neither of them had a DNR order, yet their family members reacted very differently when confronted with their death. When further analyzed, it is apparent that these two cases of cardiac arrest were very different. The man in the first situation lived alone in a nursing home, which creates questions as to the kind of quality of life he would live after resuscitation. In contrast, the man in the second situation lived with his wife, and had a caring family that showed up to support him shortly after finding out there was a problem. By just spending a few minutes talking with the man and his wife, it became clear that they meant everything to each other. Therefore, she wanted nothing other than for her husband to be revived, since he had so much more to live for.
In the first situation, seeing all of the invasive procedures of CPR being performed on her father greatly influenced the woman's position on his resuscitation. However, the wife in the second situation saw the same procedures performed on her husband, but still supported the resuscitation of the man. This is a good example of when a person believes that a patient has "reached the end of life." The daughter in the first situation would have preferred to have her father go in peace, since he would never be able to recover enough to live an independent life. At best, if the man in the first situation were to make a full recovery, he would only be placed back into his solitary room in the same negligent nursing home. In contrast, if the husband from the second situation were to make a full recovery, he would be able to continue living with his loving wife and family.
While it may be interesting to observe the differences in reaction of these family members when confronted with death, their thoughts do not legally have an affect on the course of resuscitation in a pre-hospital setting. No matter how family members feel, emergency medical crews are required to initiate cardiopulmonary resuscitation efforts in the absence of a DNR. This is obviously a very controversial practice, since resuscitation is often not in the best interest for the patient. However, family members may not have the ability to make decisions for the best interest of the patient, due to their skewed beliefs of the success of CPR, as well as their emotionally impaired judgment.
Most of the issues that arise which involve the ethics of resuscitation could be resolved by implementing a standardized DNR system, so that no confusion as to a DNR order's authenticity may arise. Instead of requiring lengthy documents to authenticate a DNR, a more simple way of identifying a person's DNR could be used. For example, people with a DNR could be issued a special driver's license issued only to those with DNR orders. This would be quick and easy to identify by emergency medical crews, and are more likely to be carried on a patient than written documents.
Instead of creating a protocol which sets an age limit as to when CPR is futile, as was suggested in proposed protocols (Orlowski 1999), people should be required to fill out documentation to declare their desires for resuscitation once they reach a certain age. If this were practiced, there would be no doubt as to whether or not a person's wishes are to be resuscitated if necessary. This would be in best interest for the patient, since the most important opinion as to whether or not resuscitation should occur is the opinion of the patient themselves.
In a society where death appears to have been conquered, fewer and fewer people are able to die a quick and peaceful death without the invasive procedures of resuscitation. Many can be blamed for this injustice, from those who create medical protocols, to the media of Western society. Ultimately, it comes down to the ability to distinguish between using CPR to prolong the joy of life, or to prolong the suffering of death.
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Collins, Harry, Trevor Pinch. 2005. Dr. Golem: How to Think About Medicine. Chicago and London: The University of Chicago Press.
Karim, A.B.M.F., H.M. Kuitert, D.W.W. Newling and V. Wortman. 1998. Death. Amsterdam: VU University Press.
Orlowski, James P. 1999. Ethics in Critical Care Medicine. Hagerstown, Maryland: University Publishing Group.
Somerville, Margaret. 2001. Death Talk. Montreal & Kingston, London, Ithaca: McGill-Queen's University Press.
Timmermans, Stefan. 1999. Sudden Death and the Myth of CPR. Philadelphia: Temple University Press.