To Code or Not to Code??

F. Amos Bailey MD

Director, Palliative Care

Birmingham VAMC

Screw the Ethical Principles

This case is giving me a headache The ethical principles don’t seem to be

helpful What I need is some sort of guidance

Ethical Principles Screw UP

Autonomy – Cannot Get a Straight Answer

Offer to take responsibility for decision but ultimately no decision is made

Beneficence – Resuscitation cannot be helpful or beneficial

Non-Maleficence- Resuscitation has got to hurt particularly when there is no benefit to be gained

Justice

Justice for Mr. XG? Justice for the family? Justice for the medical providers? Justice for society?

Slow Code

Don’t run; walk. Faking it is as bad a lying. New England Journal said it was a bad

idea.

The Slow Code- Should Anyone

Rush to Its Defense

Gazelle, G. NEJM (1998)338:467-9

Slow Code

Was the idea best option in the case of Mr. XG?

However, was admittedly, not satisfactory… The scenario did not work out as planned and

patient was coded when one was not attended…

What was needed was a rule…..

Borrow a Bright Idea

Validation of a Rule for

Termination of Resuscitation

in Out-of-Hospital Cardiac Arrest.

Morrison LJ et al. NEJM (2006)335:478-87Article discusses a Rule for TOR that if applied in the Toronto area would greatly reduce the numbers of resuscitation attempts with no “statistical” effect on number of survivors.

Rule for Termination of Resuscitation

If it could work in the outpatient setting why not have one for codes in the hospital

Sick people come to the hospital and a lot of them die

A rule like this would have been helpful in the Case of Mr. XG when all the ethical principles failed us

Lets try to develop a Rule for TOR for the hospital

Disclaimer

Cardiac Arrest not Respiratory Arrest

Respiratory Arrest much more likely to be survived and have beneficence with less risk on maleficence

Often confused in discussion of codes and if counted in gives a false sense of the successfulness, for cardiac arrest

“Mostly dead I can work with.” Max( Billy Crystal) resuscitating Wesley in the Princess Bride.

Rule for Termination of Resuscitation

1 Arrest is not witnessed- If the cardiac arrest is not witnessed or detected by telemetry such that the time between arrest and the when ACLS is initiated is unknown then resuscitation will not be provided, and if started, then will be discontinued.

2. Asytole- Patients who have asytole at the time of arrest or develop asytole during resuscitation will not receive ACLS or have ACLS protocol discontinued

Murphy et al: Annals of Internal Medicine 1989; 111 (3): 199-205

van Walraven et al: Journal of American Medical Association 2001;285: 1602-06

Engdahl J;Am J Cardiol 2000 Sep 15;86(6):610-4

Rule for Termination of Resuscitation

3. DNI Order- Patients who have a Do Not Intubate order will not receive ACLS protocol since the initial step in ACLS is to secure airway and provide respiratory support. Since this cannot be reasonably done and honor the DNI order, ACLS will not be initiated and if it has been will be promptly discontinued.

Ethical Challenges of Partial Do-Not-Resuscitate (DNR) Orders: Placing DNR Orders...

Berger Arch Intern Med.2003; 163: 2270-2275.

Rule for Termination of Resuscitation

4. Return of spontaneous circulation- If spontaneous circulation is not restored within 10 minutes of initiation of ACLS protocol then resuscitation efforts will be discontinued.

5. Defibrillation- Electrical defibrillation is an effective treatment for ventricular dysrhythmia. However, if defibrillation is not effective in restoring spontaneous circulation within 10 minutes then the ACLS will discontinued

In-hospital versus out-of-hospital presentation of life-threatening ventricular arrhythmias predicts survival Epstein, A. et al. J Am Coll Cardiol, 1999; 34:1111-1116 .

Bourke Arch Intern Med 2001;161:1751-1758.Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective. Rea TD; Circulation 2003 Jun 10;107(22):2780-5. Advanced cardiac life support in out-of-hospital cardiac arrest.Stiell IG;N Engl J Med 2004 Aug 12;351(7):647-56

.

Rule for Termination of Resuscitation

6. Patients that reside in a nursing home would not receive resuscitation attempts.

7. Patients 80 years and older would not receive resuscitation attempts.

Outcome and Cost-Effectiveness of Cardiopulmonary Resuscitation after In-Hospital Cardiac Arrest in Octogenarians Paniaguaa, D et al. Cardiology 2002;97:6-11

Age and Other Determinants of Survival After In-hospital Cardiopulmonary Resuscitation O'KEEFFE s. Q J Med 1991; 81: 1005-1010

In-hospital Cardiac Arrest and Resuscitation Outcomes: Rationale for Sudden Cardiac Death Approach Rakiae, D. Croat Med J 2005;46(6):907-912

Outcomes of cardiopulmonary resuscitation in nursing homes: can we predict who will benefit? Tresh DD,Am J Med. 1993 Aug;95(2):123-30.

The Case of Mr XG; optimal outcomes

Had we had the rule: Mr XG’s family is educated that he will not benefit from resuscitation and a dnr order is written, if necessary, in spite of their disagreement.

Not having the rule (but in light of its correctness): Mr XG is coded, but briefly (slow code). This would have been the best course to take under the circumstances.

The Case

• Mr XG is 86 years old, is s/p bilateral cva and has multiple comorbidities and is sick.

• He needs to be DNR but family cannot accept this, order cannot be written.

• Dr Bailey’s instructions are not made completely clear but suggestion is that Mr XG is not meant to be coded.

• Mr XG dies, is coded, would not have been if Dr Bailey had been on the ball.

Amos’s Approach

• Tough case what’s the rule? Action

This doesn’t work very well for this case.

• Amos’s solution: devise a rule that fits the case

CPR in the Hospital• Arrest rhythms

– VF/VT 25%– Asystole/PEA 66%

• Survival– Overall (to discharge) 17%

• VF/VT 35%

• Asystole/PEA 10%

Peberdy et al., Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the national registry of cariopulmonary resuscitation. Resuscitation 58(2003): 297-308

CPR in the Hospital; survivors

Before After d/c• Residence at home 84% 51%

• Good Cerebral performance 68% 59%

• Good overall performance 48% 37%

Amos’s rule for cpr

• Don’t if unwitnessed arrest of indeterminate duration

• Don’t if asystole

• Dni equals dnr

• Stop after 10 minutes

• Don’t if nursing home resident

• Don’t if patient is > 80

CPR and Code Duration

• Survival is clearly more likely for …CPR durations of 15 minutes or less. Mortality increases from 44% for resuscitations less than 15 minutes in duration versus 95% for those that are longer. Survival is rare after 30 minutes of CPR.

Ch 16 Cardiopulmonary Resuscitation; Cohn et al., Cardiac Surgery in the Adult (NY: McGraw Hill, 2003)

CPR and Code Duration

• Recent series: – “The duration of the resuscitation attempt was

not correlated with patient survival.”

Danciu et al., A predictive model for survival after in-hospital cardiopulmonary arrest Resuscitation 62(2004): 35-42.

Cpr and Asystole

• Recent series/registries:– Survival in-hospital cpr attempts

• 25% cases: Initial rhythm vt/vf; survival rate 25%• 66% cases: initial rhythm asystole/PEA; survival

rate 10%

Peberdy et al., Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the national registry of cariopulmonary resuscitation. Resuscitation 58(2003): 297-308

CPR and Age• Recent series/registries:

– age sometimes an independent predictor of survival…

– and sometimes not….

Cooper et al., A decade of in-hospital resuscitation: outcomes and prediction of survival? Resuscitation 68(2006): 231-37.

Danciu et al., A predictive model for survival after in-hospital cardiopulmonary arrest Resuscitation 62(2004):

Cpr and age

• Recent expert opinion: – Advanced age was a negative prognostic indicator

in several early series but has no independent predictive value when comorbidities are considered.

Ch 16 Cardiopulmonary Resuscitation; Cohn et al., Cardiac Surgery in the Adult (NY: McGraw Hill, 2003)

CPR and metastatic cancer

• Recent metaanalysis:– Conclusions: Overall survival of CPR to

hospital discharge in cancer patients compares favorably to survival rates in unselected inpatients. Improved outcomes in recent years in patients with metastatic disease are likely to reflect more selective use of CPR in cancer patients, with the sickest patients deselected.

Reisfeld et al., Survival in cancer patients undergoing in-hospital resuscitation: a metaanalysis. Resuscitation 71(2006): 152-60.

CPR and rules

• Amos’s rule isn’t the right one. • One might use what we know about

resuscitation outcomes to develop a rule for offering cpr. –Any such rule would be tentative, more like a

suggestion or a general guideline than a fixed rule.

• Rules are most useful (easily applicable) when one doesn’t need them.

• The most useful (directly applicable because generally exceptionless) rules are rules we tend not to need. – Ethics: the decalogue– Medicine: e.g. when po2 is <55, give o2.

• Non-straightforward situations (for which we look for guidance) tend to be less amenable to clear direction from available rules

Algorithms/“Rules”

• The Bailey view of practice:– Rule Case Action

• Realistic view of practice– Straightforward cases: Docs engage with cases

Action• Rules describe our practice but we don’t consult a

rulebook; we see what the case demands and act.

– More difficult cases; rules serve as aids to engagement

• We turn to them not for primary guidance but to help us better grasp our more difficult cases (in what ways does it fit the rule, and in what ways not?)

Algorithms/“Rules” in Medicine

• Summarize our practice for situations of a given type (that share given properties)

• Rules draw our attention to common properties of multiple cases

• But individual cases involve multiple properties not taken cognizance of by a given rule.

• Easy rules/cases– Property governed by the rule demands use of

the rule in all (or virtually all) situations—no matter what the other aspects of the situation happen to be….

• Hard rules/cases– Property governed by the rule may or may not

demand its use depending upon other properties the situations bears.

– i.e. : rules for hard cases are defeasible

“rules are made to be broken”

Algorithms/“Rules” in Medicine

Algorithms/rules in medicine

• Suitability for resuscitation is the kind of property that makes for a “hard case”; any rule we try to make for this issue will be defeasible.

• Easy cases/properties: lets have rigid rules and live by them

• Hard cases/properties: lets consider abstract information we have and make decisions after grappling with the case and grasping it in its full individuality.

• Rigid rules for hard cases (such as suitability for resuscitation) are a recipe for disaster.

Algorithms/rules in medicine

Mr XG

• It is clear that Mr XG, by the time he’s in Safe Harbor at BVAMC, needs to receive comfort care and be DNR.

• The difficulty in the case is that his surrogate decision-makers, his family, haven’t gotten to this conclusion.

Amos’s options that night

1) Compassionately but firmly tell the patient’s family that Mr XG would receive everything he needed for comfort and would not be resuscitated in the event of an arrest.

Amos’s options for that night

2) Leave the patient without a DNR order and resign himself to the patient being coded in spite of that not being the right thing for Mr. XG.

Amos’s actual choice

• Defacto but concealed DNR order in the form of instructions to call him when the patient died. – Right thing for the patient– Leaves Amos compromised in regard to the

family

patient inadvertently coded; Amos gets the worst of possible worlds

Tough cases

• Engage identify the difficulty

• Consider abstract knowledge (rules) but realize that these will likely be less important than – a good grasp of the case– a good intention to resolve it in the patient’s

interest.