Just the other day I was called to see a patient coming up to the Intensive Care Unit with a diagnosis of pneumonia. Upon my arrival the patient is “hanging in there” with the blood pressure in the 60’ and 70’s systolic.

This is a no-brainer situation - the patient is in sepsis and septic shock. Early intravenous antibiotics and aggressive resuscitation is what this gentleman needs right now. Per the ER report he had already been given three liters of intravenous fluids with the blood pressure barely budging.

The patient needs a central venous catheter so that the vasoactive medications (vasopressors) could be given to maintain his blood pressure.

As I am grabbing the central line kit, the nurse is trying to reason with me - “Why do a central line if he is DNR (Do Not Resuscitate)?"

The patient was, indeed, DNR which means no aggressive treatment like mechanical ventilation or chest compression in case of a cardiac arrest. So, where do you draw the line between treatment, aggressive treatment and resuscitation?

There is no easy answer. It all depends on individual circumstances. Thus, there is a great deal of confusion among the general public and even health care professionals about this.

Talking to the patient (or the family if the patient is unable to communicate) is probably the only way that those important decisions should be made.

What to do if there is no time to talk, just like in the case above? In these cases we, physicians, often have to make that decision on behalf of the patient. The default tactic in most cases is to do everything you can to stabilize the patient first and then have a discussion with the family or the patient.

Not that you have to exclude the family at any point in the patient care process, it’s just that a Code Status discussion is better to have when things are relatively stable. The discussion often goes way beyond the question - “Do you want us to resuscitate him/her or not?”.

The family has to understand the implications of the decision they are making in the current situation.

Often, when asked about the code status for their loved one the family produces a living will - the document that is supposed to clarify the patient's preferences on this matter.

Having read hundreds of those documents I can attest that the wording in most of those documents is just too general. Most living wills state something like: “If I am in a terminal condition and there is no reasonable hope for recovery...do not resuscitate.”

In some cases it is plain obvious that the patient is not going to do well. If the patient comes with a massive brain insult of whatever cause there is, indeed, no hope for recovery. Most cases, though, fall into the gray area.

Often, it is obvious that the patient is sick but things could go either way. And in the case of an adverse outcome the physician should be aware about what the patient's wishes are regarding aggressive treatment and resuscitation.

The bottom line is - there is still plenty of confusion about the resuscitation status among patients and even healthcare professionals. Careful and timely discussion with the patient and the family is, really, the only way those decisions should be made.

The other day I was sitting outside a patient’s room waiting for the hospital employee to finish taking orders from the patient for meals for the following day.
The patient had to decide between chicken, beef and fish for lunch.
Once the orders were put into the computer, I stepped into the room to see the patient.

The patient was an 87 year old man with a widely metastatic cancer. His condition was terminal and no further treatment was offered by his oncologist. My plan was to discuss two issues with the patient -- pain control and resuscitation status. It’s good practice to decide if the patient wants to be resuscitated in the case of cardiac arrest. It is also a good idea to make this decision when things are relatively stable and the patient can take the time to think about it.

As I was talking to the patient, I couldn’t help but think that my conversation is no different than the one the patient had had earlier with the cafeteria employee. The options were different, but that’s about it;
“What do you want us to try for pain control?” was my question.
“We can try some vicodin or percocet. How about some morphine to get things under better control?” I asked.

The conversation regarding code(resuscitation) status went the same way:
“If your heart stops, do you want us to put you on a breathing machine and perform CPR?” The patient paused for a minute and as if picking items from a menu, stated that he is Ok with CPR but does not want to be on a machine. At that point I realized that the patient had very little understanding of what resuscitation meant and what the possible outcomes were. Performing CPR without providing adequate blood oxygenation will have limited effect, and vice versa, putting somebody on a breathing machine and not doing CPR will have no benefit in the case of a cardiac arrest.

It is our responsibility to help the patient to make the decision regarding life support by providing education and counseling on end of life issues. Sometimes, you, as a physician, will have to make that decision and communicate to the patient why CPR should not be performed. We do not offer patients surgery or a procedure if there is no benefit from doing it. Why should we offer CPR if the patient is unlikely to benefit from it and could, actually, develop complications related to CPR.

I strongly advice against resuscitation in the following circumstances:

When cardiac arrest will likely happen as a result of a severe and irreversible metabolic and physiologic change. At that point, performing CPR is futile since you cannot reverse the condition leading to it. The example would be a severe multiple organ failure and Acute Respiratory Distress Syndrome due to overwhelming sepsis. If patient’s lungs are so damaged that there is not adequate oxygen delivery and that causes the heart to stop, doing CPR is not going to bring the patient back. Of course, all the treatment options for the underlying condition should be exhausted first.

When overall life expectancy is poor due to an incurable disease or condition. The patient with a terminal, widely metastatic cancer should not spent his last days on a ventilator.

When CPR could actually cause more harm than good. Performing CPR on a 89 year old female with a severe osteoporosis will like lead to multiple rib fractures and potentially lung damage.

Having said that, it’s almost like a patient’s “right” to get CPR before death and refusing to perform it might have legal consequences. What we need is better education for the public on end of life issues and better protection for the physicians for refusing to provide futile care.