CORRESPONDENCE dents are extremely vulnerable and that special safeguards need to be maintained. Perhaps the predominant safeguard of ail should This comes in response to be that of personal autonomy. To make a policy by judging a& Thomas Finucane’s editorial (Am J Med. 1993;95:121-122.) regarding other’s quality of life is certainly attempted cardiopulmonary resus- dangerous. We should all talk with our patients a little more to find citation in nursing homes. We are currently conducting an out when-in their opinion-a lifeAHCPR-funded study of prefer- or-death risk is worth taking. Linda A. O’Brien, RN, MA ences for life-sustaining measures Jeane Ann G&so, MD, MSC among nursing home residents. University of Pennsylvania This study involves 400 residents Medical Cents from approximately 48 randomly PhSladelphia, Pennsylvania selected nursing homes in four states (Pennsylvania, New Jersey, Submitted September’ZO, 1993 and accepted October 28,1993. Maryland, and Delaware). What we are clearly learning is that a substantial percentage of nursing The Reply: I thank O’Brien and Grisso for home residents can assimilate intheir comments. Two points require formation regarding the use of lie support measures, can engage in clarification. First, the editorial was discussions of preferences for life in part a comment on the work of support, and can and do express Tresch et al’ in the samevolume of specific preferences for various the Jownal. These authors suggested that, for nursing home resitreatments (CPR, hospitalization in the event of acute illness, and dents who want attempted cartube feeding). In addition, we have diopulmonary resuscitation (CPR), learned from the first 300 study it “should be initiated only if the arparticipants enrolled that a large rest is witnessed, and should be proportion of residents opt for continued only if the patient’s CPR to be attempted even after re- rhythm is VF.” I agreed, in the ediceiving comprehensive informa- torial, with O’Brien and Grisso that this is still “the position of withtion regarding the procedure. Dr. Finucane’s comments raise holding potentially life-sustaining two particularly disturbing issues. therapy from some people simply When, in the history of our health because the likelihood of its failure care system, have we systemati- has exceeded an arbitrary limit.” Second, but at the same time, cally denied a group of people lifesustaining measures because of a the futility debate is in full swing low likelihood of success?What of and it is hard to propose seriously AIDS patients, multiple organ that t,he likelihood of an interventransplant [email protected]
and even in- tion’s success should have no effants conjoined at birth? fect on whether we offer or proIn the course of interviewing vide it to the patient. How should study participants, we frequently a physician respond to a person hear “I want to live. If there is any who requests 5 surgeries to resect chance of survival, I would like to the 5 known metastases from a take that chance.” It appears that small-cell lung cancer? Do we refor many nursing home residents, ally just ask the patient and respect life has not become so burdensome his or her autonomy? that they are eager to forego treatO’Brien and Grisso’sstudy of dement having any chance of benefit. cision-making among nursing We do agree with Dr. Finucane’s home residents will be an imporassertion that nursing home resi- tant contribution. What is already
CARDIOPULWlONARY RESUSCtTATION tN NUfSlNG HOMES To the Editor:
of [email protected]
known about attempted CPR in nursing homes? It is rarely aL tempted,‘8 rarely successful;U and almost never repeated on those on whom it has been previously been successful.‘r5 This pattern could represent widespread neglect in the industry, as thousands of patients who really want attempted CPR may be dying without it. An alternative explanation is that the aides, nurses, and physicians who are at the bedside when a patient dies make a reasonable judgment about benefits and burdens and simply do not attempt CPR. This might be called “compassion,” a term for which there is no room in a rigid, rights-based, consenting-adults, lawyerly model. A survey of several hundred clinicians found that four times as many physicians and nurses were “concerned about the provision of overly burdensome treatment than about under-treatment.“6 These decisions, whether compassionate or neglectful, are based on more than simple likelihoods of %uccess” (re-establishing blood pressure) or “survive (Iiving to hospital discharge). They depend in part on the patient’s suffering, the burden of the treatment, and the kind of life that might follow if the attempted CPR were “successful.” In summary, making decisions for these very vulnerable people, who may be anxious, depressed, demented, is complicated and difficult. I’m afraid that simply offering a menu of options may not be best for the patient. Many patients in this situation would benefit from intelligent compassion, from being cared for, and taken care of, by the team, including the doctor. Thomas E. Finucane, MD The Johns Hopkins Geriatrics Ceatw Baltimore, Maryland 1. Tresch DD, Neahring JM, Duthie EH, et al. Outcomes of cardiopulmonary resuscitation in nursing homes: can we predict who WIII benefit? Am J Med. 1993:95:123-130.