Cardiopulmonary resuscitation performed in patients with terminal illness in Chiang Mai University Hospital, Thailand

Sudarat Sittisombuta, Edgar J Loveb and Chitr Sitthi-amornc,d

a Faculty of Nursing, Chiang Mai University, 110 Intavaroros Road, Chiang Mai 50200, Thailand.
b Department of Community Health Sciences, University of Calgary, 3330 Hospital Drive, NW, T2N 4N1 Calgary, Alberta, Canada.
c College of Public Health, Chulalongkorn University, 10th Floor, Institute Building 3, Soi Chula 62, Phyathai Road, Bangkok 10330, Thailand.
d Department of Medicine, Faculty of Medicine, Chulalongkorn University, Thailand.

Sudarat Sittisombut, Faculty of Nursing, Chiang Mai University, 110 Intavaroros Road, Chiang Mai 50200, Thailand. E-mail: sudarat{at}mail.nurse.cmu.ac.th

Abstract

Background The original target of cardiopulmonary resuscitation (CPR) was victims of acute cardiopulmonary arrest. However, the use of CPR has expanded to a wide variety of patients including those with terminal illness for whom CPR is futile. The objective of this study was to identify the incidence of CPR performed, the severity of illness and the outcome of CPR attempted in terminal illness in a teaching hospital.

Methods Cardiopulmonary resuscitation attempted in terminal illness was retrospectively assessed from the medical records of hospital deaths with any one of eight life-threatening diagnoses during a 3.5-year period.

Results Of 532 hospital deaths from terminal illness, 411 records (77.3%) were reviewed and abstracted. Most of the 411 patients had a low pre-CPR functional status. Generally, CPR was performed in 270 (65.7%) cases; 114 of those given CPR (42.2%) initially survived, but all died shortly after the manoeuvre. The high death rate following CPR may reflect both terminal illnesses and the severity of pre-event functional capacity of patients.

Conclusion The criteria for CPR in this group of patients need to be re-assessed and use of a Cerebral Performance Categories (CPC) score may be helpful.

Keywords Cardiopulmonary resuscitation, do-not-resuscitate order, terminal illness

Accepted 7 February 2001

Cardiopulmonary resuscitation (CPR) was originally developed for victims of sudden cardiac or respiratory arrest.1 In many institutions, however, it is a standard practice to attempt CPR on any patient who has a cardiopulmonary arrest regardless of the underlying disease. The exceptions are patients who request not to receive such treatment.2,3

Cardiopulmonary resuscitation should be withheld from many patients, especially those with terminal illness.4 It is clear that survival after CPR is related to the underlying disease(s) that lead to the arrest5 and that patients with certain conditions very rarely survive.69 There is also potential harm in that patients may be kept alive for days or weeks undergoing painful and dehumanizing procedures with no conceivable medical benefit.1012

In western countries, CPR and do-not-resuscitate (DNR) policies have been developed to facilitate decision making.13 In Thailand, such policies are not yet generally available. Moreover, the final care for terminal illness has never been explored and remains unknown. In this study, we reviewed the medical records of terminally ill patients who died in hospital to assess the incidence of CPR, the functional capacity before cardiopulmonary arrest and the outcome after CPR.

Methods

This study aimed to assess the incidence of CPR use in terminal illness, the Cerebral Performance Categories (CPC) score before cardiopulmonary arrest and the result of CPR attempts. Since, the study did not involve any intervention, Institutional Review Board approval was not needed but the confidentiality of patients and clinicians was respected.14

For the purpose of this study, the criteria of Bayer et al. were used. They defined terminal illness as ‘an illness in which, on the basis of the best available diagnostic criteria and in the light of available therapies, a reasonable estimation can be made prospectively and with a high probability that a person will die within a relatively short time’.11 The overall 6-month mortality for these illnesses has been reported as 47%.15

Medical records of patients who died in Chiang Mai University Hospital from 1 January 1996 to 30 June 1999 were searched by computer for eight diagnoses: (1) non-small-cell lung cancer stage III or IV; (2) multi-organ system failure with sepsis; (3) exacerbation of chronic obstructive pulmonary disease; (4) exacerbation of congestive heart failure; (5) non-traumatic coma; (6) carcinoma of colon with metastasis to liver; (7) acute respiratory failure; (8) end-stage liver disease. Of 7569 total hospital deaths during the study period, 532 deaths with one or more of these diagnoses were identified. However, 118 medical records were missing and three other records were subsequently excluded due to missing data. The remaining 411 records (77.3%) were reviewed. Functional status pre-CPR was also assessed using the CPC score. A CPC score of 1 reflected good cerebral performance, 2 and 3 = moderate and severe cerebral disability, 4 = comatose, vegetative stage, and 5 = brain death/organ donation candidate.16

Results

Of 411 terminally ill, half of the cases had two or more diseases as major causes of death. Pre-event functional capacity as measured by the CPC score was generally poor (Table 1Go). Only 26 records (6.3%) mentioned that the physician had informed the relatives of the patient's condition and/or prognosis.


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Table 1 Number of patients with the specific diagnoses, cardiopulmonary resuscitation (CPR) attempted or no-CPR, Cerebral Performance Categories (CPC) score, intervention in place at time of cardiopulmonary arrest and the result of CPR
 
Among 411 cases, CPR was performed in 270 cases (65.7%), 114 (42.2%) initially survived but subsequently died. The frequency of CPR performed varied from 1 to 6 times with the majority of cases (79.6%) receiving CPR only once. Patients with multi-organ system failure with sepsis, CPC of 3, and patients receiving mechanical ventilation were more likely to be resuscitated (P < 0.001, P < 0.001 and P = 0.003, respectively). Surprisingly, patients who had not had ECG monitoring were more likely to be resuscitated than those who had been monitored (P = 0.004). Of the 141 cases who died without CPR attempt, the DNR order was written or verbally expressed in only 39 cases (9.5%).

Discussion

As far as we can determine, there is only one paper dealing with CPR in Thailand.17 In this study we examined the inpatient charts of 411 deaths over a 3.5-year period with at least one of eight life-threatening diagnoses.

The list of diagnoses included some that are definitely terminal (#1,2,6,8) and some which may be reversible (#3,4,5,7). Unfortunately, patients in the latter group also suffered with other irreversible pathology.

Of 411 patients, 65.7% received CPR prior to death. Most patients receiving CPR had a CPC of 3 or 4 indicating that they were in a very poor condition. Only a small number of patients and relatives were informed about diagnoses and prognoses. Since cardiopulmonary arrest is likely to occur in terminal illnesses, there is little ethical justification for not discussing it in advance.18

Generally, northern Thai people seldom complain about minor symptoms and are fond of using natural herbs or traditional medicine to relieve symptoms. Therefore, late diagnoses are common. Families usually attempt to seek the best care for their relatives, but traditionally, treatment decisions are usually left to the physician.

The use of CPR might decrease if patients and relatives realize that the illness is terminal. Most northern Thai people prefer to die at home. Death in hospital means that the body should not be brought back home and therefore, the funeral ceremony and all rituals have to be performed at the temple, adding to the family costs.

We believe that if patients and their families had adequate information and had greater decision-making power, their welfare would be enhanced and futile CPR attempts might be reduced. Our findings will hopefully stimulate responsible clinicians to improve CPR practices by developing CPR and DNR policies.

Acknowledgments

The authors wish to thank the Thailand Research Fund for partial support of this study.

Notes

This paper has been presented at the RGJ-Ph.D. Congress I in Khanchanaburi Province, Thailand, May 2000.

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