Make the choice to die with dignity

Aging column by Dr. Michael Gordon (01-25-2002)
Reprinted with permission from the Toronto Star

Emily (a pseudonym) was taken aback when the doctor asked to discuss the Do Not Resuscitate (DNR) order with regard to her 87-year-old father who had been admitted to the complex continuing care facility.

"Why are you asking me this?" the daughter asked anxiously. "Is something wrong?"

"There is nothing wrong that is new," replied the doctor, "but your father is very frail. He's had a number of strokes, two heart attacks and he has diabetes. The chance of something happening one day is quite high and we should be sure that we make the right decision now, rather than under stress in a crisis."

The daughter was silent for a moment. She and her brother had discussed the care of their father in general but had never discussed the issue of a DNR order. Her brother lived in Montreal and she didn't want to decide without discussing it with him and with her husband. She wondered why the doctor was asking her now when nothing had changed.

"The last thing I believe you want to happen is that because there is no DNR order, CPR -- which is not a pleasant experience -- be started should your father be found without a pulse or having stopped breathing," the doctor explained. "The ambulance would be called and he'd be taken to a general hospital where in all likelihood he would die, not in a place where people know him and care for him, but in a strange emergency room."

"But aren't you asking me to let my father die, when he might be saved by CPR?" asked the daughter.

"I don't look at it that way," he replied. "CPR is unlikely to save your father. All the other necessary treatments that we agreed to, should he develop other illnesses, will be provided."

This dialogue is typical of what often happens in long-term care and chronic care facilities. It's an important conversation with family that needs to take place, but often doesn't.

Some long-term care organizations have adopted a policy of not even offering CPR to patients and residents. This policy might come as a shock to family members.

Other facilities do provide CPR if there is no DNR order. However, they may not provide it if the circumstances of the "cardiac arrest" are such that all the medical evidence points to the fact that CPR would not work and that it would only subject a dying person to one last indignity.

It's often difficult for families to understand why there is so much reluctance to provide CPR in long-term care and chronic care facilities. Some may believe erroneously that it is an attempt to save money and that, if provided, their loved one could be "brought back to life". The way CPR is presented on medical shows, one would think that almost everyone is "saved".

But according to studies of the efficacy or success rate of CPR in the long-term care and chronic care facilities, very few, if any, patients and residents who experience "cardiac arrest" are successfully resuscitated. Some may respond immediately to the treatment, but usually die hours or days later, often having been on a respirator in a state of unconsciousness or semi-consciousness.

Studies from the few long-term care or chronic care facilities that have full CPR capability, with physicians and other trained staff on-site day and night, indicate that the majority of attempts at CPR result in failure. Most long-term care and chronic care facilities do not have the capability to provide full CPR. Therefore, fully effective CPR (which requires special expertise, experience and equipment) usually does not get started until an emergency vehicle arrives. If effective CPR is not started within a few minutes, the results are uniformly dismal. This is the case for the vast majority of patients and residents in long-term care and chronic care facilities.

But, there is a more important issue at stake here. What would most frail, elderly people want as their last moments of life, especially if they have lost much of the physical and cognitive function that has given meaning to their life? If they understand that the likelihood of benefit from CPR is poor and that the process is undignified, wouldn't most prefer to die peacefully or through a sudden cardiac arrest? It's best if such individuals had discussed the issue with their loved ones or had indicated their wishes through a living will, but this is often not the case.

Emily spoke to her brother. They recognized that their father, since his last stroke, had not been able to communicate or participate in almost anything, even eating, without great effort. They recalled that he'd been upset when their mother had been in that state and that he hadn't wanted any heroic measures for her. They decided he would want the same for himself.

The DNR order was put on the chart. Emily felt relieved that her father would die in peace when the time came, but that in the meantime he would receive loving care.

Dr. Michael Gordon is Vice-President of Medical Service at Baycrest, a professor of Medicine at the University of Toronto, and a member of the National Advisory Council on Aging.

These columns appeared in The Toronto Star in 2001 and 2002 and are reprinted with permission.