Giving CPR left me seeking reassurance
BMJ 2024; 387 doi: https://doi.org/10.1136/bmj.q2121 (Published 11 December 2024) Cite this as: BMJ 2024;387:q2121
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Dear Editor
I’m very sorry that Lynsey Duncan felt so unsupported after valiantly doing her very very best for her father-in-law -- in such difficult circumstances.
‘Linda’ told me a remarkably similar story(1) - both had instinct and training kick in; both worried about breaking ribs when they did CPR; and both questioned their own actions, despite trying extraordinarily hard before the emergency service arrived. Both had no support.
But I know Linda wants to share some additional and different lessons.
Please don’t think for a moment I’m criticising Lynsey Dean or their family -- each individual is and must be different.
During the winter, Linda’s mum was treated four times with a chest infection and she told Linda that she was ‘fed up with life’. Sadly, however, there was no consideration of advance care planning.
Linda’s mum had ROSC after the first CPR episode, and then again after more CPR in the ambulance on the way to the hospital. As she drove in, Linda “had had time to think…” and resolved to speak up, even though: “… nobody teaches you the words to say when you want the doctors to let somebody go. Not to [try to] resuscitate them if their heart stops again.”
Linda told me: “No one wants their mum to die. But who wants their mum to suffer? I loved my mum enough to try to save her. But I also loved her enough to let her go.”
Please let me repeat that I’m not criticising Lynsey Dean or their family - each individual has different circumstances.
But I do want all clinicians - and that means You - to take action rather than simply worrying it is not the right time or that they are not the right person to start important conversations touching on death (2,3,4)
Please consider how much more difficult it was for Linda, standing in an emergency room with her unconscious mother. Linda had to lead -- in an extraordinarily challenging situation.
Maybe also think what it's like for families after unsuccessful CPR at home. When as an out-of-hours GP, I saw a frail, elderly person lying dead on the floor with their clothing in disarray and an intubation tube still protruding from their mouth, I was frequently told: “At least everything was done.” I always nodded respectfully, but privately I often thought: “What about sitting with your relative, holding hands, and telling her you love her?” That’s surely another sort of “everything” that might have been done. And this was exactly what Linda told me she so regretted not being able to do.
1) Mawer, Caroline. How Can We Make Out-of-Hospital CPR More Family Centered? AMA J Ethics 2019 21(5):e461-469 https://journalofethics.ama-assn.org/article/how-can-we-make-out-hospita... Accessed 21 Dec, 2024
2) Berry P. Why did that man receive CPR?—an imaginary inquiry. Illusions of Autonomy. January 16, 2015. https://illusionsofautonomy.wordpress.com/2015/01/16/why-did-that-man-re.... Accessed 21 Dec, 2024
3) Berry P. Why did that man receive CPR?—part 2. Illusions of Autonomy. January 22, 2015. https://illusionsofautonomy.wordpress.com/2015/01/22/why-did-that-man-re.... Accessed 21 Dec, 2024
4) Berry P. Why did that man receive CPR?—part 3. Illusions of Autonomy. January 30, 2015. https://illusionsofautonomy.wordpress.com/2015/01/30/why-did-that-man-re.... Accessed 21 Dec, 2024
Competing interests: No competing interests
Re: Giving CPR left me seeking reassurance
Dear Editor
This sounds like a traumatic experience, and I am glad that the author has found support and been able to debrief. This featuring in the educational section moves me to comment.
In the take home messages section, CPR is framed implicitly and repeatedly as an obligation; e.g. “How could you support someone who has had to give CPR?”. Perhaps the problem is the perception that CPR is our duty if we care about the person. To do otherwise would be a dereliction or disservice. I think this stems from our tendency to neglect some essential facts of life. Death is the only inevitability after we are born. Its likelihood and imminence becomes ever greater as we age and with comorbidity. Its occurrence in this context is natural. In the state of cardiac arrest, we are unconscious. Therefore, not suffering, and without any agency or expectation.
It also stems from a cultural misperception that CPR is a treatment that we should not withhold. But the person has already suffered a terminal event, that but for our intervention, would leave them at peace, and not suffering. Before the inception of CPR in the 1960s this would have been the status quo. Since then we have appended the reasonable aims of medicine- life preservation and prolongation if that is the patient’s wish- with an obligatory attempt at death reversal.
As is common in cardiac arrests, the author alludes to several ominous aspects; the unavoidable delay to starting resuscitation, the prioritisation of the presumed thoughts of those ‘left behind’, her own inner voice and intuition, the dissenting view of the closest relative. That she persisted and subsequently blamed herself for her perceived failure is a testament to how ingrained and normalised the cultural expectation is to ‘just do something’, and to resist the only inevitability of life.
When my mother distraughtly called me about my father who had unexpectedly collapsed and was undergoing multiple cycles of CPR with the paramedics, I am grateful for two things. That we’d had sufficient, largely irreverent, discussions of death for me to have a handle on my father’s wishes, and that I had the physical distance from the situation to remain relatively clear headed. The counterfactual, a tiny possibility of survival and living to appreciate life again, was outweighed by the much greater possibility that we could inflict suffering, and the reality that he was not suffering in that moment.
No doubt the moment of death will be unexpected and a shock for many relatives and bystanders to witness. Perhaps equally valid take home messages would be a reminder that out of hospital CPR has only a 7.8% chance of ‘success’ (1), yet over half of people believe it to be over 75% (2). That discussing death with family, and understanding their wishes is worthwhile. A compassionate approach, as well as supporting those who have felt moved to perform CPR, is to avoid further concretising the edict to perform CPR, and legitimise acceptance, without guilt.
References
1. https://www.resus.org.uk/about-us/news-and-events/new-data-reveals-decre...
2. Bandolin NS, Huang W, Beckett L, et al. Perspectives of emergency department attendees on outcomes of resuscitation efforts: origins and impact on cardiopulmonary resuscitation preference. Emergency Medicine Journal 2020;37:611-616.
Competing interests: No competing interests