Cardiopulmonary resuscitation (CPR) was introduced in the 1960s. It aims to restart the heart after cardiac arrests. CPR includes chest compressions, electric shocks to the chest, ventilation of lungs and injection of drugs into the body.
But due to exaggerated benefits depicted in the media, people vastly overestimate CPR efficacy. In actual fact, only 20% of hospitalised patients survive CPR. Success in out-of-hospital arrests is a mere 10%. This is because CPR is usually ineffective in patients with serious long-term conditions, such as severe heart, lung or kidney failure.
CPR has other downsides. It causes painful rib fractures, and injures the liver and spleen. Removing chest clothing to give electric shocks is undignified. CPR survivors typically require further critical care with ventilatory, heart and kidney support. A third of survivors sustain residual damage to the brain manifesting as personality changes and weakness.
So CPR may not prevent death in patients with serious long-term conditions, but could cause further discomfort and indignity before death. This is against the fundamental right of Indians to live with dignity, which includes the right to die with dignity as well.
In May 2020, the Indian Council of Medical Research (ICMR) published its long-awaited ‘do-not-attempt resuscitation’ (DNA-R) guidelines. These guidelines aim to support doctors and patients jointly agreeing to not attempt resuscitation if there is low chance of success. But although these guidelines are helpful, they also fall short.
Many COVID-19 deaths occur with rapid deterioration in individuals with serious long-term conditions. CPR attempts are typically futile. Understandably, in emergency admissions, there is limited time to discuss DNA-R. Visiting restrictions due to virus infectivity make discussions with families less feasible. Faced with sudden deterioration and no DNA-R agreement, doctors are obliged to perform unwarranted CPR.
Ideally, in patients with serious long-term conditions, advanced DNA-R decisions made well ahead of deterioration allow patients to make informed choices about whether they wish to be resuscitated. Unfortunately, the ICMR guidelines don’t emphasise proactive advanced-DNA-R decisions. The guidelines suggest that decisions typically be made in hospital admissions, where death is imminent in hours or days, in advanced incurable disease. The guidelines emphasise that DNA-R decisions are not advance directives.
Advance directives, first permitted by the Supreme Court of India in 2018, support the right to die with dignity. They allow patients to make legally binding decisions to withdraw treatment should they enter a vegetative state or develop a terminal illness. However, the mandated process is quite cumbersome. Patients must sign an advance directive with two witnesses and a magistrate. When patients fall ill and are admitted to hospital, a hospital board with four senior clinicians needs to draft a preliminary report to be forwarded to the district collector, who will then arrange for another four-doctor medical panel, including the chief district medical officer. The panel then advises a magistrate, who will visit the hospital to finally instruct treatment withdrawal.
In a pandemic, advance directives are not practical to seek or implement. Impromptu, rushed DNA-R decisions are not ideal or easy to obtain. Therefore, patients with serious long-term conditions can be deprived of a death with dignity.
What should we do?
First, ICMR should update the guidelines emphasising advanced DNA-R discussions for all patients with serious long-term health conditions. Doctors as part of their duty of care must initiate discussion on CPR in vulnerable patients at the earliest possible opportunity, in outpatient or inpatient settings. This responsibility must be stipulated in the Code of Medical Ethics Regulations. A standardised pan-India advanced DNA-R form should be introduced with copies for patients, recognisable in any healthcare setting if clinical deterioration occurs.
Decisions should be individualised and must respect patient autonomy. Clinicians should emphasise that advanced DNA-R decisions don’t influence any other active treatment. Such preemptive informed discussions could allow half of elderly or seriously ill patients to change their mind about wishing to undergo CPR after a cardiac arrest. If clinicians feel strongly that CPR would be futile and patients don’t agree, a second opinion could be sought.
Second, doctors should receive mandatory training on end-of-life care and communication skills to help discuss DNA-R with patients and families. Patient information leaflets and educational resources could complement such conversations.
Third, a public awareness campaign should be launched to educate society at large regarding the advantages and disadvantages of CPR. This will help patients initiate conversations with physicians about CPR. Averting futile CPR could also reduce hospital costs of subsequent critical care and, as a bonus, free up much-needed critical care beds for other patients.
It is a common misconception that Indians are reluctant to consider DNA-R. A significant fraction of individuals from all faiths do not oppose DNA-R. To address cultural barriers if any, religious heads could encourage communities to consider the benefits of advanced DNA-R decisions.
Awareness of the concept of CPR will help all Indians. It must be offered to those who can benefit from resuscitation. However, only 2% of Indians believe they can perform CPR. Just 0.1% have ever attempted it. Some 90% of road traffic accidents victims are transported to hospitals by non-CPR trained individuals. So a structured nationwide programme to train Indians in CPR should be launched via schools, universities and workplaces, with the guidance of the Indian Resuscitation Council.
In sum, the new ICMR guidelines – despite being a step in the right direction – don’t fulfil the fundamental right of all Indians to die with dignity. ICMR should work with patients, doctors and the government to promote advanced DNA-R conversations as part of standard medical care for all Indians with serious long-term conditions.
Dr Saif Razvi, MD, FRCP is a consultant neurologist in the United Kingdom. The views expressed here are the author’s own and don’t represent those of the organisations the author works for.