Token resuscitation attempts on hopelessly ill patients prolong suffering

Resuscitating hopelessly ill patients too slowly to save their lives can be an invasive and undignified procedure that prolongs death and suffering, according to the November issue of Journal of Clinical Nursing.

Nursing ethics lecturer Jacinta Kelly, from Trinity College Dublin, has called for clinical and legal guidelines to be issued to prevent the practice of slow codes and highlighted the need for better communication about do not resuscitate (DNR) orders.

She hopes that this step will help healthcare professionals who often find themselves in a very difficult and unenviable position.

“If a DNR order does not exist, healthcare professionals are expected to attempt resuscitation even if the patient is terminally ill” she explains. “Slow codes are seen as a way of going through the motions, being kinder to desperately ill patients and avoiding potential legal action. But it is unfair on the patient and also very difficult for staff who are keen to see patients end their life in a peaceful and dignified way.”

Jacinta Kelly’s comments come after she carried out a review of international research into resuscitation covering more than 40 years. This underlined the changing face of end of life care – with more people dying in hospital than home – and the difficult legal and ethical dilemmas that medical advances bring for healthcare staff.

“DNR orders are normally noted on a terminally ill patient’s chart and, as a result, no attempt is made to resuscitate them if they suffer a cardiac arrest” she explains. “However, it is clear from my research that, despite the availability of DNR orders, the grey area of slow codes - where healthcare professionals resuscitate a patient too slowly for their efforts to be successful – is still an issue.

“Patients need to give their consent for a DNR order to be put on their notes, but my review suggests that there are often reasons why this is not possible and slow codes end up being used.

“For example, the patient can be too ill, unconscious or not mentally competent to make a decision or the healthcare professional may be worried or uncomfortable about bringing up a subject that may distress the patient or their families or deprive them of hope. There are also issues about dealing with unrealistic expectations when it comes to resuscitation and the strong religious convictions of some patients and families.

“While some researchers argue that it is kinder to use slow codes when a patient is devastatingly ill, others maintain that it is harmful and deceptive, disregards the wishes of patients and their families and deprives patients of a peaceful death.”

Jacinta Kelly says that, at the very least, further research is needed into why slow codes are still used and how nurses and doctors decide to carry out token resuscitation attempts.

“Diminishing family support and increased access to healthcare mean that more people are now dying in hospital than at home in Ireland” she adds. “That inevitably leads to an increase in initiatives that prolong life and ongoing debates about how to provide terminally ill patients with a peaceful and dignified death.”

Jacinta Kelly’s review found that researchers agree that all decisions relating to cardiac resuscitation should be made in accordance with up-to-date clinical guidelines.

“No clinical guidelines exist in Ireland and my research indicates that national and local guidelines should be devised to aid decision-making” she says.

“My review also shows that professionals are sometimes encouraged to instigate slow codes because of their perceived fear of being sued. This points to the need for legislative clarity in Ireland, including legally-binding advanced directives - such as living wills - which already exist in countries like America.

“It also shows that patients and their families often don’t understand what cardiac resuscitation involves and sensitive communication skills are needed to explain this emotive area.

“The evidence also suggests that written information on cardiac resuscitation should be devised, to explain that a do not resuscitate order only covers that specific procedure and will not result in other treatments being withheld or the patient receiving substandard care.“

• Literature review: decision-making regarding slow resuscitation. Kelly J. Journal of Clinical Nursing. 16, 1989-1998. (November 2007)

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