Is CPR meaningful?
How can we prevent a patient who is registered as “do not resuscitate” still being resuscitated? How meaningful is CPR really, Nardo van der Meer wonders in this blog.
Image: © Nationale Beeldbank
Mrs. Breskens, 84 years old, was brought to the Emergency Room. The facts: “Out-of-Hospital Cardiac arrest,” known to cardiologist De Vries for heart failure, reponse time 10 minutes, no CPR from bystander, first VF rhythm, short-term chest compressions and after 2x 150 joules again rhythm and output.
In the background stood an older man, leaning on a walking stick. Presumably her husband. This is a familiar scene to most of my IC colleagues in the Netherlands. However, there was important extra information. In our EMR, the patient was registered as a “do not resuscitate.”
15,000 cardiac arrests
Every year in the Netherlands, more than 15,000 patients have a cardiac arrest outside the hospital. Thanks to the efforts of many organizations, we have a system in the Netherlands that enables the fire department, police, ambulance service, and many volunteers to respond quickly and appropriately when someone suddenly collapses on the street or at home. Yet, in these cases we are dealing with a very deadly situation; more than 75% of people do not survive a sudden cardiac arrest.
There are two ways to look at this number: ”despite all efforts, 75% do not make it” or “thanks to all the efforts, 25% will be fine.” But even then the question remains: what good are those numbers? What ensures that you, as a person or attending physician, says at some point: in case of a cardiac arrest we will not resuscitate. This is often an individual choice based on feeling, emotion, trust, and, hopefully, on the few sparse facts.
Proverbial hothouse plant
In a well-nuanced and personal article in the De Volkskrant, medical journalist Alliette Jonkers described her search for the value of output numbers. In her article she rightly stresses that after CPR, if you survive, you often do not end up as the proverbial hothouse plant. That is true. But it is only true if you survive.
The cited homegrown research shows that of all patient-related factors, age determines the outcome of a CPR: 16% survival rate in the group of 70-79 years old and 8% in the group aged 80 and older. Factors such as comorbidity proved far less important than expected. Much more important is whether the resuscitation itself was started quickly and effectively.
Awareness that it has been for nothing
But these numbers tell nothing about the process of hospital stay. Quite often a patient arrives at the hospital and somewhere during the treatment process the awareness arises that it has been for nothing. This can happen at the beginning, in the Emergency Room, but it can also arise after a number of days of IC-treatment. In the Netherlands, in cases of permanent neurological damage we choose to be very reluctant about further intervention such as artificial respiration, antibiotics, renewed resuscitation, etc... Many people still die in hospital after initial resuscitation. That process is insufficiently highlighted in the article.
Mrs. Breskens was admitted to Intensive Care by us. Once we started, we went through a complete and heavily protocoled course of treatment in the ICU. This meant that only after three days could we say with certainty that her brain was damaged by a lack of oxygen to the extent that she would never wake up again, let alone lead an independent life. We stopped the treatment and the woman died in the presence of her family. Unfortunately, she belonged to the 92% group. But actually she did not want to be where she now was, because she did not want to be resuscitated at all.
Could we have prevented this together? Could we have prevented the resuscitation? Should we not have stopped the treatment immediately after entering the ER? We cannot reach agreement on it. You cannot win the argument with numbers alone: does it really matter whether you have a 20 or 35% chance of survival? Does that determine your decision?
It is a personal choice that will have to be discussed with all the knowledge at your disposal, especially when you are 70 or older, whether you live at home or in an institution. With some exceptions, it is an individual decision whether resuscitation is worthwhile. It is the patient who mainly decides. Once he has made that choice, he should let as many people as possible know about it. The fact is that we do not have a sound and readily available information system for sharing the information.