'Code Blue' Deciding How Much Medical Effort is Enough

April 19, 1992|By KENNETH BURKE

Anna Richardson is eighty three years old. She is not unlike many patients in the autumn of their lives; she has collected a vast number of illnesses associated with aging. She has high blood pressure, cataracts, and severe arthritis; she is unable to walk without assistance. Anna -- the name, of course, is not real -- also suffers from senile dementia.

Anna does not know where she is, nor who are her visitors; she has been unable to comprehend these simple things for many years. Her dementia is advanced to the point that she even forgets sometimes that she is eating; hours later you may find her in bed, still holding food in her mouth, forgetting to swallow.

As if these sufferings were not enough, Anna also has cancer of the colon, which has spread to her liver and other organs. There is no hope for cure for Anna; with metastatic cancer as diffuse as hers, there would be no chance for survival in a patient half her age.

Anna came to us for chemotherapy. Now, after completing this bout of "chemo," she has developed severe bone marrow depression as a side effect from her therapy; her white blood cells, vital to ward off any infection, have dropped to a dangerously low level. Her "white count" is so low that she is now in reverse isolation -- visitors must wear protective garb and masks in fear of contaminating her with a life threatening infection.

In spite of these precautions, she has developed a urinary tract infection, and is not responding to antibiotics. Her prognosis is bleak; the end may be near as this infection spreads and ravages what little left she has to offer in defense.

We have approached Anna's family and made it clear that she may die from this infection. She could suffer "sudden death" for a variety of reasons, at any moment. Anna's family, however, insists that "everything" be done, including instituting a "code blue," or cardiopulmonary resuscitation, should the need arise.

As a physician, and as a feeling person, I have many problems with this decision, on many different levels.

There are thousands of "Annas" all over the country, in hospitals and nursing homes. The quality of her life is -- I do not think that anyone could argue -- quite abysmal. I doubt that any of you who read this would like to trade places with her. Yet her family, and families like her's, chose a route which will only continue her suffering.

In patients such as these, why must we refuse to let their suffering end? If their hearts should suddenly stop, wouldn't that be a peaceful end to such tragic suffering? For the families, perhaps, it is a refusal to come to terms with death, and the terminal separation that it brings. In our society, we are unwilling to accept death because it represents the final defeat; we are a society founded on struggle.

But perhaps it is because these families do not understand the implications of what "doing everything" means. CPR is not a pretty sight; it is vastly different from what television portrays it to be. In a word, it is brutal. I cannot describe the nausea which overcomes me when I perform CPR on an elderly person -- and feel the crack of their ribs beneath my hands while I administer compressions to their chests. Perhaps if everyone had the chance to see what real CPR was like, they would not be so quick to subject the "Annas" of this world to such torture.

I do believe that there is a place for CPR, but it is not appropriate to subject someone to that when they have a terminal illness or no hope for recovery to a meaningful way of life. I realize that I speak in broad sweeping terms when I use words like "meaningful," but as I stated earlier, I doubt that there would be any debate over this in the case of Anna.

My arguments up until this point have been based solely on philosophical grounds. But, medicine being the science that it is, has naturally investigated the efficacy of CPR in the elderly. In August 1989, the Annals of Internal Medicine published an editorial entitled "Resuscitation in the Elderly: A Blessing or a Curse?"

The author pointed out that one investigation looked at 503 patients over 69 years of age who suffered cardiac arrest. Some of these occurred outside the hospital, and some while in the hospital. Of 503 patients, only 110 were successfully resuscitated, initially. Of these 110, only 19 survived and were discharged. More than half of these 19 patients went to chronic care facilities (such as nursing homes) upon discharge, "presumably because of neurologic deficits." There is no mention of the quality of life enjoyed by the other fifty percent who went "home."

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