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While the Filipino people are internationally known for hospitality like no other, as well as the concept of “Bayanihan”, which espouses an innate desire to help their fellow person, less admirable values embedded within our society often throw a wrench into otherwise well-meaning intentions and actions.
Thus, in perhaps a perfect nut-shelling of the presentation that preceded his wise words, Philippine Heart Association (PHA) Cardiopulmonary Resuscitation (CPR) Council Chair Dr. Don Robespierre’s statement that “If you want to save a life, do it right” converges with the CPR Ready PH campaign slogan of “Save a Life, Learn CPR” and is a crucial lesson that must be taken to heart.
Dr. Reyes served as the host of the PHA’s recent monthly webinar “Usapang Puso Sa Puso” (UPP) which aired on Facebook live on May 24, 2022 and broke new grounds in the informative series’ history as its latest installment entitled “Kultura at Relihiyon: May issue nga ba sa CPR?” shed light on the challenges that arise when the matter of cardiopulmonary resuscitation (CPR) is challenged by religious and cultural beliefs, practices.
Alongside this edition of UPP are momentous occasions including the Council’s celebration of 40 years of unwavering efforts to establish the country as a CPR-ready nation, and PHA’s 52nd Annual Convention and Scientific Meeting, in conjunction with the organization’s 70th year of spearheading Cardiology in the country.
CPR administration is integral to survival
The UPP webinar opened with an enlightening and witty discussion on Pinoy culture, religion, and CPR by Cebu Institute of Medicine Clinical Professor Dr. Ma. Celine T. Aquino, and featured guest speakers “Doctorney” Atty. Patricia Ramos-Syson, MD, associate professor of Medical Jurisprudence at the University of Santo Tomas (UST), Dr. Domicias L. Abacite, Angeles University Foundation Medical Center Section assistant chair, and UST Department of Medical Ethics Chair Dr. Roland M. Panaligan.
Dr. Aquino spoke of the most prominent cultural traits that impact the practice of proper CPR, such as “pakikisama” (following trends), “porma” (trying to look cool), “hiya” (being too shy), “amor propio” (self-love to the point of arrogance), “machismo”, “bahala na” (giving up and letting the cards fall where they may”, and hubris that prevents many Filipinos from asking for proper instruction on things, for the sake of saving face.
Addressing these heavily imbibed core values, according to Dr. Aquino, must be done by providing the proper perspective to Filipinos, in order to promote receiving proper training.
Dr. Reyes also called on those in the entertainment industry to improve the accuracy and soundness of medical actions, as those commonly shown in popular media, such as defibrillating a patient that has already flatlined, have been proven false by practitioners.
Additionally, within the first six minutes of sudden cardiac arrest, CPR administration is integral to survival, however, because of the aforementioned values, as well as the threat of exposure due to the Covid-19 global pandemic, bystanders may be reluctant to act in the event of an emergency, hindering the chance to minimize damage.
The next segment discussed the termination of resuscitation in Basic Life Support (BLS), wherein Dr. Abacite explained the decision-making process doctors adhere to, with regard to whether or not CPR should continue.
Religious, cultural, and legal ramification
Dr. Abacite cited the American Heart Association’s (AHA) guidelines which stipulate three criteria, also known as the termination of resuscitation rule, to be met before CPR is deemed futile and thus halted: for BLS, cardiac arrest is not witnessed by emergency medical services personnel, there is no return of spontaneous circulation, and no Automated External Defibrillator (AED) shock delivered.
For ACLS, which is marked by access to essential cardiac equipment and medication, an additional criterion of no bystander CPR performed.
In order for the termination of resuscitation rule to take effect, all parameters set by the AHA must be met; the absence of even just one, whether for BLS or ACLS, will not necessitate termination, Dr. Abacite clarified.
Moving to the next topic, the speakers discussed the religious, cultural, and legal ramifications of two medical cases: a 32-year-old male who was brought to the hospital after being found unconscious due to brain hemorrhaging. His live-in partner insisted that ACLS continue despite 30 minutes of non-response until his family members arrived.
The second case was that of a 72-year-old Chinese male suffering from prostate cancer, whose condition had severely worsened due to multiple complications and instances of cardiac arrest, prompting his doctor to discuss a do-not-resuscitate (DNR) order with his family, who were not warm to the idea as they believe that as long as their kin is living, there is hope.
“Preciousness of life, importance of its protection common ground among religions”
Recounting Dr. Reyes’ earlier sentiment, Advanced Cardiac Life Support (ACLS) is a “rigid science” wherein “the science and protocol behind the things we do in resuscitation are challenged by the peculiarities, idiosyncrasies, eccentricities in the expression of religion and culture”, leading to hurdles that medical practitioners must overcome by means of understanding without compromising care administered.
Weighing in on the two cases, it was discussed that the 32-year-old seemed a futile case as ACLS had not resulted in the return of circulation, however, because the person pushing for continued CPR past 30 minutes was his live-in partner and not spouse, legal representation became complicated.
Dr. Abacite also spoke of how the AHA’s guidelines for CPR are not absolute as some studies have indicated that resuscitation can be continued for up to 40 minutes with positive results.
Meanwhile, Dr. Panaligan shared that when it comes to religious and cultural beliefs impacting medical procedures, such as the case of the 72-year-old, understanding that science and technology are not the only points of view held by some and that it’s a constant balancing act in our culture, between these fields.
In general, “the preciousness of life and the importance of its protection are common ground among religions”, Dr. Panaligan stated, adding that the belief of humans being caretakers and not owners of their bodies is shared as well.
Furthermore, Dr. Panaligan said that death and dying are typically not things that Filipinos remain in denial about, as these are seen as part of a divine plan by the devout, however, the discussion of a DNR order prior to an indication of futility in treatment is seen as a morbid topic, explaining the hesitancy of most to proactively touch on the subject and the need for doctors to approach this with the utmost sensitivity.
Effective communication is integral for understanding
Covering the legal aspect of the cases, Atty. Reyes-Syson began her talk by stating that the “constitution is always in favor of life”, and is thus the main thrust of the judicial side of all things medical, citing the Hippocratic Oath of physicians to treat to the best of their abilities.
With regard to CPR performance, so long as one remains within the established standard and code of conduct then no crimes would be committed, and the most that could occur are additional costs in the case of prolonged efforts, in which case the issue of who would be shouldering these, comes into play.
On the topic of if there is a “right to die” as there is the constitutional right to live, it was explained that while there is no such stipulation, patients do have the right to refuse treatment, which absolves a physician of any legal liability should this be chosen with informed consent, prior.
Expounding on the futility of treatment, the different types were enumerated: Physiological (unresponsive to treatment), Quantitative (less than 1% chance of survival as determined by the physician), Qualitative (should treatment be successful, the patient’s quality of life will be virtually non-existent), Imminent Demise (treatment will only delay an inevitable death that will occur in not much time), and Lethal (patient has an underlying terminal condition that will not be affected by treatment).
Ultimately, the speakers agreed that clear and effective communication is the top, integral factor in avoiding misunderstandings and possible conflicts with regard to religious, cultural beliefs, and medical practices such as CPR. (✓)