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Do Not Resuscitate

This article delves into the complexities of deciding whether to undergo resuscitation in medical emergencies. It explains resuscitation methods and the common misconceptions surrounding outcomes, particularly in older adults. By discussing the nuances of resuscitation decisions and advocating for informed choices, the article aims to empower readers to make decisions aligned with their values and preferences.

What does this mean?

Resuscitation—Bringing someone who is Unconscious, Not breathing, Heart stopped back to a conscious state.  

Which methods are used?

  • CPR - Cardiopulmonary Resuscitation

  • Defibrillation -  An attempt to bring heart back to a normal rhythm with an electric shock

  • Intubation/ Ventilation - The use of an artificial breathing machine
     

Understanding Resuscitation: Addressing Common Misconceptions

I wanted to write about this because I find there is a lot of misunderstanding out there. In fact, when I ask this question, “Do You Want To Be Resuscitated?” almost everyone says the same thing:

“Yes, try and resuscitate me, but I don’t want to end up a vegetable.”

The problem; no one can say BEFORE a resuscitation attempt how successful it will be. There basically are three major outcomes:

--Back to previous level of functioning (actually quite rare)

--Resuscitated but at a lower level of functioning

--Passed away

In other words AFTER the resuscitation, one may end up on a ventilator and unable to leave the hospital. But one couldn’t tell prior to CPR that this would be the outcome.

Factors Influencing Decision-Making in Resuscitation

How to decide? I think that for the most part we decide based upon what we EXPECT the outcome to be. Young people expect that it will all work out. Those who are ninety tend to think the opposite. So, let’s try and help everyone out by giving statistics.

The average person is not even close to correct on outcomes. In fact, most overestimate likelihood of success by 60%. It’s likely because most people state that their information came from television, not their physician.

Statistics and Studies on Resuscitation Outcomes

In a study by Kaldjian in 2009, The average survival to discharge rate for adults who suffer in-hospital arrest is 17 to 20% Virtually unchanged in the last 40 years despite all of our advances. Which means…when asked the question, the average person believe the likelihood of surviving is about 75 to 80% when in fact it is generally under 20%.

Why is this important?

I tend to feel that there are two paradigms:

No doubt you will survive a Code Blue without any deficit whatsoever No doubt you will not survive.
If the first, we would generally all say, give it a try.
If the second, we would say don’t try. Why not? I would answer this by saying, no one would want to hurt someone knowing it won’t be of any benefit.
Which means, that if the likelihood is low enough, more would tend to choose Do Not Resuscitate.

What’s worse, based on extensive reading, I found the estimate by Kaldjian to be overly optimistic.  Below is a list of numerous studies regarding likelihood of survival.   What stands out is how poorly people do after the age of just seventy.  See the list of studies below.  

Age and Survival Rates in Resuscitation

What’s worse, based on extensive reading, I found the estimate by Kaldjian to be overly optimistic. Below is a list of numerous studies regarding likelihood of survival. What stands out is how poorly people do after the age of just seventy. See the list of studies below.

Estimates of survival depend widely upon the study.


--12,000 patients treated by emergency services in Seattle over 24 years (1977 to 2001).  Survival to hospital discharge 17.5%  Circulation. 2003;107(22):2780

--547,153 patients in Japan with out of hospital sudden cardiac arrest between 2005 and 2009 was about 2%.  If the event was witnessed, 3%.  And, if witnessed and the condition was ventricular fibrillation, as high as 20%.  Circulation. 2012;126(24):2834

--70,027 patients in the United States between 2005 and 2012, survival to discharge was as high as 8.3%. Circulation. 2014;130(21):1876

--34,291 patients in Canada between 2002 and 2011, survival one year later was as high as 11.8% Circulation. 2014;130(21):1883

--6,999 patients in Australia between 2010 and 2012, survival one year later was as high as 12.2% with more than half reporting good neurologic recovery and functional status. Circulation. 2015;131(2):174

The two studies that I found surprising dealt with age.  Specifically the age of 70.   It's true, these studies are older, but they are sobering.

--399 CPR efforts in 329 veterans was performed to evalute the observation that few geriatric patients were discharged alive after they underwent CPR.   This was a 1988 study from the VA in Houston, Texas.  JAMA. 1988;260(14):2069


If cardiac arrest was in those age 70 and older:   31% survived the CPR.  28% survived for twenty-four hours.  0% lived to discharge.  
 

If cardiac arrest was in those younger than 70:    43% survived the CPR.   39% survived for twenty-four hours. 16% survived to discharge. 

--In a 1989 study from Beth Israel Hospital in Boston, Massachusetts the goal was to determine the success rate of CPR in the elderly.  503 patients aged 70 and over 22% survived initially but only 3.8% survived to hospital discharge.  
 

Unwitnessed arrests only 1 person out of 116 survived (1%).   Only 2 out of 244 patients (2%) survived if the event was out of the hospital. 

 

Ann Intern Med. 1989;111(3):199

Critique of the POLST Form and Alternative Approach

The POLST form:  Physician Orders for Life-Sustaining Treatment

Why I don’t like it.  Two main reasons:  It’s confusing and…how does it help sitting on the fridge?

Confusing—the first statement says, “Attempt Resuscitation/ CPR (requires full treatment in section B)”

 

This I think is unfair.  Why can’t you say I’d like CPR attempted, but I do NOT want intubation/ ventilation?  Or I do NOT want defibrillation?  But, you can’t make choices on this form.

The problem with the refrigerator—A loved one is found down.  Immediately, 911 is called.  The paramedics race to your house to help and then someone says, “but look at the refrigerator, it says do nothing.”  At that point, what are they supposed to do?  Pay attention to the refrigerator or the loved one screaming at them to help.  (I also can’t state enough that seconds count, is that the time we want the paramedic to be reading the POLST form?)

 

HOW TO CALL 911 IF SOMEONE IS A DNR. 

 

My recommendation for someone who is a DNR is to do the following:    When you call 911 you say, “My loved one does NOT want to be resuscitated.  But, I’m not sure if this is something simple or if their heart has stopped, can you evaluate them for me?”   Maybe they just passed out.  Perhaps their glucose is low.  Who knows. 

Understanding Advanced Directives and Medical Power of Attorney

Advanced Directives: A written statement of a person’s wishes regarding medical treatment; often including a living will, made to ensure those wishes are carried out should the person be no longer able to communicate them to a doctor. A difference between this and the POLST form is that this is for the entire life, not just the end. For example, would you want chemotherapy if diagnosed with cancer.

Medical Power of Attorney (very similar to a Living Will): Someone who makes medical decisions on your behalf when you are unable. Think coma or severe dementia.

Summary and Conclusion: Making Informed Decisions in Resuscitation Choices

I think the reason why many medical professionals are concerned that too many people choose Full Code or “Try Everything Doctor” is summed up excellently below from an article in the New Yorker.

“It is an open secret in medicine that CPR is both brutal and rarely effective. The procedure begins at death, when someone loses a pulse. This can happen because of heart problems—a blockage in a coronary artery, say—or when other organs cause cardiac arrest: lung failure depriving the heart of oxygen, kidney failure causing a buildup of toxins. CPR is designed to keep blood flowing to the brain in these situations. It requires a hundred chest compressions per minute, two inches deep, to the beat of the song “Stayin’ Alive,” and using a defibrillator to deliver an electric shock to the chest. In hospitals, it also includes I.V. medications to help the heartbeat, and a ventilator to help the patient breathe. The result, done correctly, is akin to assault. The force of compressions can shatter ribs and breastbones, puncture lungs, bruise the heart, and cause major blood vessels to rupture. Repeated electrical shocks can burn flesh. Even if the procedure restores a heartbeat, brain damage—whether mild memory loss or a vegetative state—occurs in forty percent of hospitalized patients

What I recommend generally is a slight variation of the standard question. Mainly because I feel we must incorporate time in the decision. The reason why hospital codes are more successful, the time when the heart stops or someone stops breathing is noted often immediately. But, at home…this is often not the case.

If someone is otherwise doing well and is under age 75 is to Attempt Resuscitation IF and only IF the event is witnessed. If it is unwitnessed, likely the person has been down for more than five minutes and the likelihood of a good outcome is close to zero.

I know this is complicated and it is perhaps the most difficult decision we can be asked about our health. I am hoping that this provided you with some information to help you make a decision that is right for you. And please, if you have any specific questions, let me know at your next appointment.

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