CARDIOPULMONARY RESUSCITATION

    CPR was invented to allow interruption of and salvage from sudden cardiac death in individuals who have unexpected, premature death.  CPR rapidly became a defacto treatment for all individuals, unless prohibited by a physician’s order. A major “obstacle” to accurate futility judgments is the over-estimation of treatment success at the end of life. The effectiveness of CPR, for example, is commonly over-estimated by both physicians and the public.(1) This is to some extent due to the high success rate of CPR (67%) depicted in medical drama on television.(2) In reality, CPR’s true effectiveness is quite limited. With in-hospital cardiac arrest, general survival rates are reported at 10-20%, but are only 10-11% in patients over 65 and 3.5% in patients over 85 years of age. Following out-of-hospital arrest, only 5% of all patients are discharged with intact brain function. Elderly nursing home patients with out-of-hospital arrest only have 1-2% survival.(3) These statistics are not widely appreciated, much less applied consistently in making CPR decisions. One study found that when CPR outcome data was shared with people, it decreased their stated desire for CPR in a variety of medical scenarios.(4)

    Patients and families are often reluctant to accept Do Not Attempt Resuscitation (DNAR) status due to legitimate concern that the level of medical care for their loved one will be reduced. This obstacle to DNAR decisions is likely to worsen as managed care and nursing shortages increase. A further source of legitimate concern is that physicians are reluctant to give adequate palliative analgesia and sedation due to personal bias, concern about addiction, or fear of being accused of euthanasia if medication intended to alleviate suffering also hastens death. Physicians may also be concerned that categorically withholding statistically ineffective or investigational therapy from patients who are hopelessly ill may prevent the discovery of new, effective treatments for such individuals in the future. Although it is very reasonable to argue that aggressive treatment should be undertaken for the advancement of medical science, the vast majority of futile care goes unanalyzed and undocumented and contributes little to medical knowledge.

    Another obstacle to futility-based DNAR decisions is the failure of hospital policy to heed professional guidelines for the appropriate use of CPR.  As early as 1974, guidelines published by the National Conference on CPR stated that the purpose of CPR is the prevention of sudden, unexpected death and that it is not indicated in certain situations, such as in cases of terminal, irreversible illness where death is not unexpected.(5) The American Medical Association’s guidelines stipulate that efforts should be made to resuscitate patients who suffer cardiac or respiratory arrest except when administration of CPR would be futile or not in accord with the desires or best interests of the patient.(6) Despite these official recommendations, hospital policies typically mandate full resuscitation unless there is explicit consent for a DNAR order.(7) The result is that physicians are routinely called to the bedside of a frail, terminally ill patient on whom full resuscitation efforts have already been initiated. There is typically no effective, routine system in place for protecting individuals from such trauma, apart from case-by-case application of DNAR orders.” 

    A common error is that patients and/or families go through the agonizing decision to make the individual DNR while in the hospital but fail to continue the order upon discharge. In Florida, a specific, canary yellow colored physician order form (Florida Department of Health Form 1896) is required for out-of-hospital DNR orders. Other states have adopted more comprehensive orders (see Figure 2 POLST form), which allow decisions about other end-of-life treatment choices by the patient through the physician and, importantly, promote dialogue regarding the specific treatment choices addressed. It is important to note that a POLST form is used in conjunction with an Advance Directive by reinforcing the patient’s medical treatment decisions through physician orders.

^[1] Wagg A, Kinirons M, Stewart K. Cardiopulmonary resuscitation: doctors & nurses expect too much. J R Coll Physicians of London. 1995;29:20-24.
^[2] Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles & Misinformation. New Engl J Med. 1996;334:1578-1582.
^[3] Basta L., Plunkitt K., Shassy R., & Gamouras G. Cardiopulmonary Resuscitation in the Elderly: Defining the Limits of Appropriateness. Am J Geriatric Cardiol. 1998; 7:46-55.
^[4] Schonwetter RS, Walker RM, Kramer DR, Robinson BE. Resuscitation decision making in the elderly: the value of outcome data. J Gen Intern Med. 1993;8:295-300.
^[5] Anonymous. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). V. Medico legal considerations and recommendations. JAMA. 1974;227:Suppl:864-868.
^[6] Anonymous. Guidelines for the appropriate use of do-not-resuscitate orders. Council on Ethical & Judicial Affairs, American Medical Association. JAMA. 1991;265:1868-1871.
^[7] Doty WD, Walker RM. Medical Futility. Clin Cardiol 2000;23(Suppl.II):II-11.

 

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