Quality of life assessment and DNACPR decisions: unsafe, but unavoidable

There has been much discussion about ‘quality of life’ (QOL) judgments in DNACPR decision making recently. As the doctors censured for including ‘Down’s syndrome’ on a DNACPR form have learnt, it is never wise to refer to QOL. Such an assessment implies that the patient’s life, either now or following resuscitation, is insufficiently ‘good’ to warrant continued existence. That is clearly inappropriate. It is also perplexing, because I remember clearly that DNACPR forms used to include a box labelled ‘poor quality of life’ for us to tick!  The habit of considering QOL remains with us – and I would contend that it is important we do not ignore this aspect, for the assessment of quality remains highly relevant.

 

It is far safer to use ‘CPR likely to be ineffective’ as justification for a DNACPR decision. This is a far more concrete. The patient is debilitated, has a weak heart, terrible lungs…you can confidently predict that cardiac massage or electric shocks will not restart the heart. A binary outcome…alive or dead, no grey areas, no pejorative forecasts. Not so. The fact is that in making this ‘efficacy’ prediction we do in fact make a QOL calculation. ‘Ineffective’ merges with ‘poor QOL’, and they cannot be separated.

 

The overlap exists because resuscitation frequently does result in a restoration of the heartbeat. Life continues, but unless the patient wakes quickly, is able to breathe off a ventilator and has a blood pressure sufficient to perfuse their organs without infusions, its quality will indeed be poor in the short term. This is a worthwhile sacrifice if the end result, after days, weeks or months in intensive care, is discharge home to the care of loved ones, but statistics show that this is rare. So, although doctors may say that resuscitation will not work, they know that in a reasonable number of cases it may in fact cause the heart to restart. But they have made a judgment that the burden of treatment, be it the initial resuscitation or the inevitable admission to intensive care that must follow, is not outweighed by the potential benefit.

 

We can debate the fallibility of quality, and criticise those who fall into the trap of referring to it on paper, but we are dishonest if we deny making quality judgments when making DNACPR decisions.

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