Saturday, August 25, 2018

To Resuscitate or Not to Resuscitate

by Rebecca Omlor (@BeccaOm15)

The code bell goes off overhead calling for a rapid attempt to try to bring a patient back to life. Who is on the receiving end? Is it a frail older adult with dementia, a patient with multiple medical problems, or an otherwise healthy adult who recently underwent a cardiac catheterization for a myocardial infarction?

If this was the scenario in 2018, a team would rush to that patient and begin cardiopulmonary resuscitation (CPR) along with advanced cardiac life support (ACLS) including the use of medications and external defibrillation, if indicated, to attempt to revive the patient. While we put all this effort in, according to data from 2003, we have a little less than a 50/50 chance of getting that person’s heart beating again, and only 17% of these patients will survive to discharge1. There is no regard for how ill the patient is, what their pre-hospital functional ability was, or what might be the best-case scenario if they survive. If a patient states that he or she wants to be resuscitated, that is going to happen.

If this were the early 1960s, we would be looking at a very different scenario. According to the original group that published on the utilization of CPR, they had a very limited scope of when CPR was indicated.

Not all patients should have cardiopulmonary resuscitation attempted. Some evaluation should be made before proceeding. The cardiac arrest should be sudden and unexpected. The patient should not be in the terminal stages of a malignant or chronic disease, and there should be some possibility of a return to a functional existence. The rigid time limit of 3 to 5 minutes since the onset of arrest of cardiac output should not be exceeded. In regard to the latter when there is a genuine question of the duration of arrest, resuscitation should be attempted.2

In 1961, the understanding was that CPR would be used thoughtfully. It was viewed as a finite resource that would only be executed in cases where there would be known benefit. They hold to the understanding that if someone has been dead long enough to begin to develop brain injury, the benefit of CPR is significantly diminished and should not be attempted.

Today, we seem to disregard the limitations of CPR. Many people who work in healthcare can recount stories of resuscitation attempts on people who have been down longer than the 3-5 minute range only to have people remain in unresponsive states with minimal brainstem function only. We have stories about people we felt were knocking on death’s door where we tried multiple times to yank them back from the inevitable because that was their wish. We feel as if we are fighting nature, as if death is the ultimate enemy that we should somehow be able to overcome.

If we are to take the recommendations from 1961 to heart, then resuscitation should be viewed like any invasive procedure. As with surgery, if the medical team does not feel that there is meaningful benefit or that the harms outweigh the benefits, then resuscitation should not be recommended or attempted. Thoughtful discussions need to occur with patients about the ramifications and most likely outcomes, just as with any other informed consent. My hope is that more and more people will begin to realize that CPR seen on TV dramas is not reality and the potential harms that come from it can vastly outweigh the benefits in many cases.

This is the first Pallimed post by Rebecca Omlor, MD is a palliative care doctor at the Wake Forest Baptist Medical Center. She has over 500 pictures of her four fur-children on her phone and enjoys bragging about them to anyone willing to listen.

To see more Pallimed posts on resuscitation click here.

References

1. Ramenofsky DH and Weissman DE. Fast facts and concepts #179: CPR survival in the hospital setting. Palliative Care Network of Wisconsin. . Updated July 2015. Accessed August 17, 2018.

2. Jude JR, Kouwenhoven WB, Knickerbocker GG. Cardiac Arrest; Report of Application of External Cardiac Massage on 118 Patients. JAMA. 1961;178(11):1063–1070.

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