End of life planning and medical intervention

Posted it on Facebook and reposting it
https://www.facebook.com/dr.santosh.pradhan/posts/10155944812092471?comment_id=10155953262987471&reply_comment_id=10155955091577471&notif_id=1558789067099066&notif_t=feed_comment

The controversy of CPR (Cardiopulmonary Resuscitation) in Nepal -especially in cases where the patient has known poor premorbid condition and the doctor knows its futile. This post excludes all other cases of cardiac arrest where the patients were known to be previously fit and well.

I want to raise some concerns to both our medical professional colleagues/policy makers and to general public
I raise this after having many instances of healthcare adventures and personal experience of “Decision to proceed with CPR” at the time of unresponsiveness. I am also aware of general public/family pressuring doctors to proceed with CPR/life prolonging intervention (past experience of known political leader brought in unresponsiveness/dead). These are my personal views and I apologize unreservedly in advance if my questions cause anyone (doctor or general public) undue distress or they feel offended, and I want to assure you that is not the intention of this post.

I. Doctors/Medical Professionals:
Why do Doctors ask relatives whether they want to proceed with CPR or not, at the crucial time of unresponsiveness/end of life/cardiac arrest? Why are the relatives asked to choose an intervention, the outcome of which they know nothing about? General public (not all) do not have all the medical knowledge and they have to rely on doctor’s advice. It is the duty of doctor to give impartial advice to patient and family in a timely manner, especially when they know about the poor ongoing health condition (irreversible). If they are not fit for general anaesthesia/sedation (ASA 4/5), then why do the doctors ask whether to perform CPR or not? If the doctors ask family, very rarely family will say “NO for CPR” esp when asked abruptly at time of unresponsiveness. Its unfair to the family/relative to bear the guilt that they decided not to proceed with CPR (when they do not know what the success rate of CPR in that case). If the doctor informs them as a planned event, in a clinic or at time of admission pre-empting that this may happen next hour /day/week/month, and they have time to think and discuss among themselves, there might be a chance that they absorb the fact that NOT to proceed with CPR in an event of cardiac arrest/unresponsiveness is in best interests of the patient. But why doctors put the burden of guilt to family that they have to decide about not to proceed with CPR esp when they are already stressed out with end of life situation? I question all the Hospitals of Nepal (most private hospitals are called “Hospital and Research Centre”), how many CPR calls for in-hospital/admitted patients (NOT brought in unresponsive in Emergency Department) they recorded in last 12 months and how many were discharged with near normal recovery? This is not a research question, a simple audit standard.
Questions to all Nepalese Hospitals Chiefs/Health Ministry/policy makers/Doctors

1. Does Any hospital have a Do NOT Attempt CPR (DNACPR) or Escalation treatment plan policy/form that is considered proactively and filled in cases where the doctors agree that CPR would be futile? Do the doctors discuss with the Patient (with or without presence of family) when they are able to comprehend discussion, whether they want to proceed with CPR in an event of cardiac arrest, explaining what is CPR, what is the likely success rate in their particular case (premorbid state), and what may follow CPR (intubation, ICU admission, prolonging of life/dying process)?
2. We all plan birth (either in hospital/health centre or home/suitable environment) and doctors make necessary arrangements (sometimes few months in advance). Why don’t the doctors give equal importance to death and necessary information is given to patient and family? Have they considered giving information to patient/family that CPR can be painful, and it may prolong the dying process?
3. When the doctors know that CPR is 100% futile because of preexisting condition and terminal disease, is it ethical to proceed with CPR even if the family insists? There is this conflict of interest that if CPR is performed +/-ICU admission, it will generate further substantial income even when the doctors know that they won’t survive. So is this conflict of interest (financial gain) preventing doctors and policy makers to pre-empt CPR decision or DNACPR and make necessary policies? I have many first-hand experience of private hospitals where the patient did not require ICU admission(as a doctor myself, I know), but the doctors advised for ICU admission, and family also got reassured (falsely) that ICU care is better (not knowing that they don't need ICU care). Of course, ICU care may (or may not) offer some relief to patient (in current state of Nepal hospitals general ward), but we need to be mindful if resources like ICU are well used and reserved to the necessary cases. IF CPR has a fixed fee (all-inclusive+ ICU admission for whatever days) but only chargeable in the event when patient is recovered and discharged home, Will doctors or hospital officials then recommend CPR in futile cases?
4. There are so many unethical practices rampant in Nepal that it is understandable that general public are confused and questions doctor’s advice and seek second opinion. What is very unfortunate is that the media and policy makers are not helping the situation and this lack of trust of general public is growing bigger. It also undermines many sincere doctors who have every intention to help patients and are morally challenged when patient/relatives questions their advice, and seek second opinion from doctor who gives advice which family want to hear.

II. General population (patients and relative): CPR is medical intervention when the patient has cardiac arrest- clinicians give external cardiac compression and respiratory support as well as drugs which initiate/prolong cardiac activities (but not necessarily improves recovery). The outcome of CPR- could be a) full recovery/ recovery with minimal organ damage/dysfunction (can be discharged home after some stay in hospital/ICU), or b)recovery with major organ dysfunction/residual damage (discharged to an institution), or c)no recovery- declare dead after certain time (may be at end of CPR or after few hours/days in ICU)
When relatives/family know that the condition of their relative is not good and prognosis is very poor, will they ask this question to the doctors proactively “in an event of cardiac arrest, is CPR or other life prolonging intervention useful?”
If the doctors says “ CPR is likely to be futile, we would not recommend it – either as planned discussion in known premorbid condition or when the patient is in cardiac arrest”, would you pressurize them by saying “please, doctor try at least few minutes?" would the doctor be seen as if they have done nothing to preserve life of your loved ones? is it necessary for doctors to be seen as heroic icon and do everything, and then say "we tried very hard, but we could not save him/her"?
It may be a common occurrence in a country where govt have not yet covered healthcare costs and public have to fully fund it, that when the doctors know that CPR may have good chance of recovery, but family chooses to withdraw because they cannot afford it (or the post CPR- ICU etc bills). This is a very unfortunate event but completely understandable when they cannot afford it. However, I am also aware when doctors do all their best and proceed with life support treatment, and the outcome is still poor/or patient dies, then the family/relatives blame doctors/hospital for negligence and pursue violent activities (and ask compensation etc).

When/how will the healthcare environment be free (or reduced) of fear of blame (for doctors) and free of suspicion (for patient/family) and we can plan/deliver the true Rest in Peace event?