In August, during my Science in the News spot on Mornings with Carmen, we talked about medical care for the frail elderly and The New Yorker article by Sunita Puri, author and palliative care and hospice physician, on the moral distress physicians experience when performing CPR on the chronically ill, terminally ill, and frail elderly in the hospital. I have adapted the transcript below, or you can listen to the spot here.
CPR works well for younger people who have a treatable injury, or the cause of death is reversible. Take, for example, Isaiah Bolton or Damar Hamlin. Both athletes sustained injuries that were due to blunt force or were due to an unknown condition. They collapsed on the field and CPR was performed. This is when CPR is appropriate and helpful and survival rates are good. CPR also increases survival when, for example, a middle-aged person collapses for unknown reasons or has a sudden heart attack. CPR can buy time until the paramedics arrive.
Where CPR is not helpful, and can even be harmful, is in the case of the elderly, or those whose bodies are frail due to chronic disease. While we tend to think of CPR as lifesaving, when you do chest compressions on someone who is frail or elderly, you could end up killing them in a violent way. You will almost certainly crack ribs. You may very well puncture a lung. And sometimes you can cause irrevocable heart damage. Dr. Puri points out that 85% of those who receive CPR in the hospital end up dying in violent pain. And only 2% of adults over 67 with chronic disease who received CPR in the hospital are alive six months later.
Many doctors see performing CPR on someone who is dying or advanced in age as cruel and violent. One of the problems with CPR in theory versus in practice is that so much medicine, including CPR, was developed and tested on people who are relatively healthy and under 60 years old. This isn’t to say CPR should never be performed in the hospital or on older people, but the reality of just how damaging and burdensome CPR can be on the body should be part of the decision of how best to care for someone in the later stages of life.
I am the co-editor of a book on the ethical care for the frail elderly. One of the collaborators on this project is a palliative care physician who will tell his patients’ families that the decision on whether to do CPR or have a Do Not Resuscitate order is not a choice between life and death. It’s the choice of your loved one dying with CPR or dying without CPR.
Television skews our views of this. We tend to of think CPR as always lifesaving and Do Not Resuscitate (DNR) orders as giving up on a person. Neither of those are true nor is it true that having a DNR means the person will receive sub-standard care. Just because it makes for good TV, that doesn’t mean it makes for good medicine.
As Christians, we need to keep a few things in mind:
- We will all die one day and every person we love will die one day. It is the Ash Wednesday lesson, “from dust you have come and to dust you shall return.” (Genesis 3:19)
- Death is not good. Some people take the verse “to live is Christ, to die is gain,” to mean death is good, but 1 Corinthians 15 tells us that death is an enemy that needed to be conquered. It wasn’t good. It was a result of the Fall. In a similar vein, when people say “death is natural” it doesn’t mean it should come naturally to us to accept death. As one seminary professor said during class: Sin separates; Christ brings together. Death separates us from our loved ones and from our bodies until the Resurrection. Christ brings us together.
- Being pro-life does not mean worshiping machines. Lydia Dugdale, a Christian physician at University of Columbia Medical Center and author of The Lost Art of Dying, said in an interview on Econtalk that miracles happen, she has seen them in her practice of medicine. She also said God does not need a ventilator to work a miracle, and he doesn’t need you go to “give him more time.” Often people want to make sure that they have done everything possible, because any of us would want to do anything to save a loved one. That is different from not accepting that the person’s body has begun shutting down and the machines are only keeping the blood flowing. (See below for a discussion on special cases.)
- There’s a saying in medicine: To cure sometimes, treat often, comfort always. There will come a point when we need to switch our medical priority from curing to comfort because curing is no longer possible. That’s hard to accept for any of us, yet barring sudden death, we will all transition from cure to comfort at some point.
Let’s unpack some of these points, because there are times when it is not clear that someone has died or when to change from curing to treating and then to comfort. That’s why each patient must be taken individually, and decisions are made between the patient (or family) and the physician, rather than blanket rules that apply to everyone.
There are a lot of misapplications of the pro-life view when it comes to things like “do not resuscitate” orders or removing someone from a ventilator. We need to be careful about what it is we are imagining how we are using terms like “brain death.” Removing someone who has clearly died while on a ventilator is not the same thing as withholding food and hydration from someone in a persistent vegetative state after accident or injury. The poorly named condition of “persistent vegetative state” means the person no longer has higher brain function, but the brain stem (involuntary actions) functions. Also, removing someone from a ventilator because it is not helping the person is not the same thing as physician-assisted suicide or terminal sedation. It’s not like flipping an off switch. There have been cases where people are weaned from a ventilator, and they are able to breathe on their own. That’s different from removing a ventilator after brain death.
There are ambiguous cases, like Jahi McMath, the young girl who had a bad reaction to anesthesia before a tonsillectomy. She survived for several years while on a ventilator and seemingly brain dead. Those ambiguous cases are rare; usually, it is very clear that death has occurred, either from heart failure or complete lack of brain function. But when it is an ambiguous case, we should default to life. Furthermore, these ambiguous cases tend to be in infants, children, or young people and often from accident, injury, or sudden onset of a disease. That is a different scenario from someone who is at the end of life due to chronic illness or decline due to advanced aging. That is a very important distinction for things like CPR.
These are not hard-and-fast rules, other than when in doubt we default life, because each person’s situation must be taken on an individual basis. This is particularly the case with the frail elderly who often have complex medical situations.
An On-Going Conversation
The most difficult thing is knowing when it is time to stop aggressive treatment and transitioning to palliative care, especially when a caregiver is making decisions for a loved one who is too incapacitated to make their own decisions. That’s why a living will can be helpful, although, as many physicians and ethicists tell me, it can’t be the only thing the family has. The best situation is when there has been good communication and an ongoing conversation as a person ages and their health declines.
Here are some bullet points from some of the resources I’ve read for the book project:
Things to NOT tell your loved ones or put in your living will:
- “I don’t want to be hooked up to a bunch of machines.” This is too ambiguous because if you press someone, they will want to be hooked up to a machine in some cases. What if, as was the case for many people with Covid or other respiratory illnesses, temporarily being on ventilator would give the lungs time to rest and heal. Most people say, “well that’s different. I’d want them to use a ventilator.” But this wasn’t what they said in their will.
What they mean is they don’t want someone pumping air through their body even if they are dying or have already died. That is a different situation from using a ventilator for treatment, which is why it’s okay to remove a ventilator if it is not treating the patient. It’s not necessarily keeping the person alive, and in fact, the person might be able to have meaningful and important interactions with loved ones or religious counselors when weaned off the ventilator. I don’t want to imply this is easy; this is a terrible burden.
I think this incredibly difficult burden is the cost of having technological capabilities, and it’s something that many of us in the bioethics world wrestle with.
- “I want everything done.” This is also too ambiguous. Of course, we want whatever can be done to save someone to be done and of course we want to live. The problem is what are you willing to do for one more day or one more month? What are you willing to give up? The options aren’t: “do you want to live, or do you want to die?” But would you rather live one week able to interact with others and participate in life in some way, or would you rather live a month or two longer in ICU where you are connected to machines and only able to interact minimally with people?
Again, these are burdensome and difficult decisions. Medical technology has saved many lives, but with the power of saving life comes the burden of acknowledging our finitude.
- What kind of quality of life do you want, at least so far as you are able to guess that? Atul Gawande in his book Being Mortal, gives an example of a daughter who asked her dad what was most important to him. He said he wanted to be able to eat ice cream and watch football in his recliner, two things she didn’t realize he even enjoyed. His statement, however, was very helpful as she had to navigate making medical decisions on his behalf. She could ask doctors, “Will he still be able to eat ice cream and watch a football game?” That meant “yes” to many medical treatments and interventions, but when it came to the point that he would not be able to do these things, she knew it was time to switch priorities from treating to comfort.