Ethics in Cancer Care Delivery—Do Not Resuscitate

Introduction

The National Cancer Act, also known as the “War on Cancer” Act, was signed into law in 1971. Thanks to the Act’s support for ongoing cancer-related research, the number of cancer survivors in the United States has been progressively increasing. Today, nearly 70% of those diagnosed with cancer will be alive after 5 years. It is predicted that in 2026 there will be 20.3 million persons in the United States who have survived cancer.

The cure rates for patients with localized cancer have steadily improved, and many patients with metastatic disease are now able to live for years with their malignancy as a chronic illness (e.g., prostate, breast, and colorectal cancers). Many unprecedented discoveries within the last few decades, most notably in the fields of molecular genetics, cancer cellular biology, and immunology, have led to the development of many novel anticancer therapeutic modalities, from molecular targeted agents to bioengineered cellular treatments. Due to these therapeutic advancements, cancer patients with advanced stage disease, once considered to be an imminently fatal diagnosis, are anticipated to have a longer life expectancy.

Thus for many patients, a diagnosis of cancer does not imply a prognosis of imminent death. Certain complex therapeutic interventions in cancer patients such as surgery, or rescue procedures such as cardiac resuscitation, are not necessarily futile or contraindicated under the appropriate circumstances. Evidence-based risk assessments, including anticipated prognosis of the malignancy, are therefore important considerations in treatment planning. To establish appropriate goals of care, these issues should be discussed with the patient and their family well in advance of acute care interventions.

In this chapter, we will review the evolving evidence on the outcomes of cardiac resuscitation as well as palliative surgery in cancer patients. We will also discuss the regulatory requirements for ensuring that patients’ rights to do not resuscitate (DNR) decisions are safeguarded, and the ethical dilemmas that such decisions could generate for clinicians.

Cardiopulmonary Resuscitation

“Closed-chest cardiac massage” was introduced into medical practice in 1960 by Kowenhoven, Jude, and Knickerbocker when they published in the Journal of the American Medical Association a series of 20 selected patients who each had an in-hospital cardiac arrest (IHCA) event that was witnessed. Their cardiac arrest events were reversed through the application of a technique of external chest compressions, accompanied by external electrical shocks in some cases. Fourteen of the 20 patients survived and left the hospital, leading to their conclusion: “The use of this technique on 20 patients has given an over-all permanent survival rate of 70%. Anyone, anywhere, can now initiate cardiac resuscitative procedures. All that is needed are two hands.”

The application of this technique, which was renamed “cardiopulmonary resuscitation,” or “CPR,” quickly caught on, and began to be applied literally “anywhere,” both within the setting of hospitals and in the community at large. Within a few years, outcomes in large series of cases were being published. One of the largest early in-hospital CPR case series included over 500 patients who had experienced an IHCA at the Royal Victoria Hospital in Montreal Canada. Published in 1967, they defined resuscitation as successful if the patient survived 24 h or longer. By this definition, resuscitation was successful in 32% of the cases, but only half of these patients (15%) recovered completely and were discharged from the hospital. These results were vastly different from those of the original publication and, until recently, have remained remarkably constant across institutions and across time. In 1987, nearly 30 years after the original study, McGrath conducted an extensive literature review of published in-hospital CPR outcomes in studies that included at least 100 patients. Forty-two publications met his criteria and in total included 12,961 patients. The summary of results demonstrated essentially the same outcomes as the early Canadian series: on average, 15% of patients had long-term survival after in-hospital CPR. An additional observation was that patients with coronary artery disease, who likely had developed an arrhythmia or asystole due to cardiac ischemia, were the group that most seemed to benefit from CPR.

Law, Regulations, and Guidelines

Rescuing patients from what previously had been fatal events, regardless that the numbers were relatively small, was considered clinically significant, and CPR became widely used. The results, however, were consistently showing that in the setting of a general hospital patient population, most patients with IHCA were not benefitting from CPR, and some who survived were left with late effects, including cognitive deficits and even in vegetative states of existence. Due to concern that CPR was not appropriate for all IHCA patients, the American Medical Association in 1974 issued a recommendation that patients be informed of risks/benefits of this procedure, and the patient’s decision regarding their preferences for CPR (or “code status”) be documented in the medical record. Nearly a decade later, in 1983, the President’s Commission for the Study of Ethical Problems in Medicine published their opinion that consent for CPR be considered implicit, unless otherwise explicitly stated with an order issued to withhold CPR. This stemmed from a position of moral reasoning that a person would rationally want to be given an opportunity, even if small, that they would survive a cardiac arrest. Cardiopulmonary resuscitation thus became the only intervention for which patient consent is required to NOT have the procedure, and an order must be written to NOT perform it.

In 1988 the Joint Commission issued a standard that hospitals must have policies regarding CPR. The Patient Self-Determination Act of 1991 further required that hospitals receiving Medicare or Medicaid funds were to inform patients of their right to self-determination, including the right to refuse life support procedures such as CPR. The American Society of Anesthesiologists (ASA), in alignment with the Patient Self-Determination Act, first published guidelines in 1993 stating that the practice of automatic perioperative suspension of DNR orders was in direct conflict with patients’ rights to self-determination. This principle has been reiterated in more current updates to the ASA’s guidelines, with support from the American College of Surgeons.