On reversing death

TAUREEF MOHAMMED

THE FIRST time I performed CPR was on Ward 54 at Port-of-Spain General Hospital. It was early in the night when the nurses alerted the on-call doctors that Mr X had no signs of life: no pulse, no breathing, no movement.

At first sight, the man looked frail. With the junior on-call doctor directing me, I kneeled on the bed, clasped my hands together, and with my weight atop, started compressions. As my hands sunk into his chest rhythmically, something unexpected happened: bones started crumbling and crackling beneath my hand.

More information about this frail man emerged. Metastatic prostate cancer: cancer had infiltrated his bones and the rest of his body. He had not been doing well. His prognosis was poor. Only a few minutes had passed before CPR was stopped and death was pronounced. I looked at the indentation my hands left on his chest –
primum non nocere, the maxim goes.

A few years later, I would have deja vu on the haematology ward at Victoria Hospital in London, Ontario. “Advanced myeloma, multiple treatments failed. I won’t prolong it,” an ICU resident said to me as I stood at the foot of the bed, looking on at the pandemonium of trying to restart someone’s heart.

Bad deaths happened everywhere.

Death occurs when a person’s heart stops beating and he/she stops breathing. Cardiopulmonary resuscitation (CPR) attempts to reverse death by restarting the heart using mechanical force (compressions), electricity (shocks), and drugs, while delivering oxygen to the lungs via a tube inserted through the mouth.

Thanks to television, CPR is one of the most misunderstood concepts in medicine. Contrary to what we see on TV, CPR is unsuccessful most of the time. Nine out of ten people who have a cardiac arrest outside of hospital die, according to the American Heart Association. That is not to say it is useless.

In June 2021, during Denmark’s opening match at Euro 2020, Christian Eriksen’s heart stopped beating and CPR was done on the pitch. Eight months later, he returned to professional football and next month he will represent Denmark at the World Cup.

But context is important.

And that’s why for all patients admitted to hospital, we ask about their wishes regarding CPR. We call it the patient’s “code status.” It becomes especially critical when someone is elderly, has a terminal illness, or a serious, irreversible life-threatening condition. In these scenarios, a person may say: do not resuscitate (DNR).

Obtaining a code status not only avoids unwanted care and futile interventions, but it also provides a segue into a person’s values, understanding and expectations. By asking, we recognise the patient’s autonomy in directing his/her own end.

But doctors and patients and/or their advocates don’t always see eye to eye when it comes to CPR. Sometimes things get so messy, the courts become involved. In 2019, the Ontario Superior Court of Justice ruled in favour of two Canadian physicians who refused to start CPR on an 88-year-old man with multiple, severe, irreversible diseases. One of several medico-legal cases related to end-of-life conflicts, Warwrzyniak v Livingstone made news throughout Ontario and prompted the College of Physicians and Surgeons of Ontario to revise its end-of-life policy.

Exploring in detail the ethical and medico-legal issues that complicate such cases is way out of my depth. However, I have not infrequently found myself at the bedside of dying patients or in family meetings, where CPR had been contentious.

On one side there is the medical team. We have been down this road before; we know how dying looks; we know how CPR looks; we get a sense when interventions are futile and do more harm than good.

Then there is the patient’s side. A person has no prior experience in his/her own death; someone doesn’t get accustomed to losing a loved one; a family plunged into despair will find solace in hope, faith, God.

And at times, especially in the ICU, it seems like 21st-century technology has added another dimension between life and death, complicating matters even more.

Reconciling all of this is not easy.

Most times communication is enough to bring everyone on the same side. In the few cases I have witnessed that remained contentious while the patient was actively dying, a bad death was the eventual outcome.

In the end, how do we avoid a bad death? A good place to start is talking about death. Don’t wait to have the difficult conversation in a hospital.

Taureef Mohammed is a graduate of UWI and a geriatric medicine fellow at Western University, Canada