Psalm 103:15: Our days on earth are like grass; like wildflowers, we bloom and die.

As a palliative care clinician, one of the things that I hope to accomplish through my work with each patient is to better understand their healthcare wishes. When meeting a new patient in the hospital, I introduce myself and the palliative care service with the following elevator speech:

“Good morning Mrs. Smith. My name is Janelle Williamson and I am a nurse practitioner with the palliative care team.” (Now at this point the patient either looks at me like I have aliens coming out of my head or they look at me with fear and say, “Am I dying?”) “My team works with patients and families who are facing serious illness. Your provider asked me to stop by today as it seems you have been dealing with a lot of difficult health issues recently.  I hope to accomplish two goals. First, I want ensure you have a good understanding of what is going on with your health. Second, I want to be certain that we, your medical team, have a good understanding of what is most important to you and the medical care you are receiving is consistent with your wishes.” At this point, patients and families generally relax and we can go on with our discussion. Or they kick me out of the room!

Resuscitation preference

And then comes the dreaded topic of preference for resuscitation. Often this has been discussed before I arrive, usually by a well meaning provider. They usually say something like, “If your heart stops, do you want us to do everything for you?” And who would say no to this? Most people want something to be done for them if their heart stops. I am frequently met with an eye roll when I ask if this is something we can discuss again. I reassure my patient and their family that I will present this information as a part of informed consent, in the same way a surgeon might present surgical options, so they can make the best decision for themself or their loved one.

Informed consent

First, I explain that a decision for CPR should be presented in the same way we present an option for surgery. We must review risks, benefits and appropriateness of this intervention. I then describe the care that they will receive in the event of cardiac or respiratory arrest (the care received when they have died.) An emergency team will be called in to the room and CPR will be initiated. CPR includes the act of chest compressions, inserting a breathing tube and placing them on life support, shocking the heart if indicated and providing emergency medications intravenously. Complications related to receiving CPR include fractured ribs, punctured lungs, bleeding into the chest and injury to the brain from lack of oxygen. I explain that the older the person is and/or the more medical problems one has, the less likely they are to survive CPR. In the event of survivaln there is a higher likelihood they will experience functional decline and decreased quality of life. I explain that in the context of a DNR order, in the event of cardiac or respiratory arrest, CPR would not be provided and instead the patient would be permitted to die. I provide reassurance that they will continue to receive the standard of medical care up to the point of death and that every effort to prevent death would be made. Do not resuscitate does not mean do not treat.

Why not just try?

CPR is an amazing, life-saving medical intervention that can be effective in the right patient population. Most believe what is seen on television, where the outcome is black or white and survival rates are over 75%. The person either lives or dies. There is little to no attention given to survival at discharge or one’s quality of life following CPR. CPR is the only medical intervention that people must opt out of. And we do a very poor job of explaining what one is likely to experience. Would you ever elect to have a surgery for yourself or a loved one without being fully informed by your provider first? I dare think not! The survival rate for in-hospital resuscitation is less than 25%. CPR does not suddenly make old organs young again or someone who has a terminal illness no longer have that illness. CPR does not suddenly take someone who is on a declining trajectory and make them miraculously well again. In these scenarios CPR often makes the survivors condition worse and the outcome is often the same with/without CPR, death. And often one difficult decision is traded for another…now a family must make the far more difficult decision to withdraw life supportive care. In my experience, it is far more difficult to decide to withdraw life supportive care than it is to make the decision to not go down that road in the first place.

So why am I saying all of this? I share this with you to educate you and encourage you to think about what you might want for yourself or an aging loved one. Have the conversation with your loved ones. Let them know of your wishes. Write your wishes down. Talk with your healthcare provider. Your family and your medical team will thank you.

For additional information…

Want to learn more about advance directives and DNR orders? Check out the following resources. Completing your advance directives doesn’t have to be expensive and don’t require an attorney. In fact, most healthcare systems assist with completion of these documents for free. Talk with your healthcare provider about support in completing these documents.

Palliative Care Program | KDHE, KS

Understand and Complete Your Advance Directives | The Joint Commission

Advance Care Planning: Advance Directives for Health Care | National Institute on Aging (nih.gov)