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Am Fam Physician. 2000;61(8):2512-2517

When a nursing home patient is in cardiopulmonary arrest, the physician must have the answers to several questions. First, what does the patient want done in the case of cardiopulmonary arrest? In the absence of the ability of the patient to provide an answer, are advance directives available? If patient capacity and advance directives are lacking, is a surrogate decision-maker available? If no proxy decision-makers are available, the decision is often made to attempt to preserve life. In this review, Finucane and Harper discuss this standard operating procedure from the point of view of policy considerations.

It is known that attempted cardiopulmonary resuscitation (ACPR) is infrequently performed in the long-term care setting and is rarely successful (successful being defined as admission to the hospital alive). Survival (defined as discharge from the hospital) is also rare. Survival with improved or intact status (neurologic or functional) is uncommon but does occur. Because ACPR is not necessarily a painless, free or dignified procedure, other questions remain to be answered. What is the benefit or harm to the patient of performing ACPR when it is unsuccessful? What about when ACPR is successful, but the patient expires within a few days as a hospital inpatient? The authors point out that these questions cannot be studied, only decided. The patients in question are usually extremely vulnerable because of functional or cognitive limitations, and a myriad of regulations protect them. However, few protective measures are in place to protect these patients against overtreatment. That is, as the system now stands, a usual presumption is that not performing ACPR is neglectful. However, it would be helpful to address what harm is done in performing ACPR. A case can be made that allocation of resources in favor of performing ACPR benefits few of these nursing home residents, and that these resources could benefit many more patients if allocated in different ways. Simply having the ability to perform ACPR may appear to many to be a logical reason to perform it, and this concept may elevate ACPR to being thought of as a “right.” The mere availability of a treatment is a poor reason to use it. All nursing homes are not required to offer ACPR. The authors point out that many nursing homes in the United States, as well as in other parts of the world, do not offer ACPR. If ACPR is an option, it may be reasonable to offer it only to a select group of patients. However, this step would likely be seen as paternalism on the one hand and neglect or abuse on the other. Some nursing homes have elected to offer ACPR only to those with a witnessed arrest, which lowers the survival rate from 3 in 100 to 3 in 1,000.

editor's note: The emphasis in the past decade on completing advance directives has encouraged physicians to talk to patients about their end-of-life wishes. However, many patients are still reluctant or unable to discuss such matters, and a decision about attempted resuscitation may fall back into the physician's lap. This excellent review by Finucane and Harper cogently summarizes considerations that should be taken into account when deciding about an ACPR policy for a facility and for an individual patient. It is the physician and the caregivers (whether that be family or staff at a nursing home) who know the patient best and can best decide whether ACPR would be part of a compassionate, coherent plan of care.—g.b.h.

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