Do Not Attempt Resuscitation: let’s have a conversation

One of the hardest parts of any doctors job is talking to patients about the end of life, and whether to try to resuscitate them or not. I often wish I could have these conversations far away in space and time from the moment a patient is actually ill.
So let’s talk about it now. 
When I sit down with a patient or their family to discuss resuscitation I always find their understanding of CPR very different from mine. We always start with the same questions.

What is CPR? It stands for cardiopulmonary resuscitation, which simply means, trying to restart (resuscitation) your heart (cardio) or lungs (pulmonary).

Which simply means if you get so sick that your heart or your lungs stopped working, we would try to restart them. 

How do we do that? Well, the process of CPR is actually quite brutal. To pump a heart that isn’t beating you have to compress it from the outside, 100-120 times a minute. To do it properly you need to squeeze the chest by 1/3 of its depth, or 5-6 cm deep. 

This sometimes breaks ribs. Trust me, it’s as horrific as it sounds. 

The next step is stripping the clothes, and placing two large electrodes on to the chest connected to a monitor and large battery that can give an electric shock. If there is a heart rhythm that can be shocked, we dial up the machine to a high energy setting, tell everyone to not touch the patient or they will get shocked themselves, and electrocute them. I’ve seen this in semi-conscious patients and it hurts. 

We then carry on with pounding on the chest. 

At some point a specially trained doctor or nurse will try and pass a breathing tube into your throat, insert tubes into the veins in your arms, neck or groin, and give large doses of heart pumping drugs. 

We cycle through this process, deciding every two minutes whether the heart can be shocked, or whether there is something else we can do. This can go on for sometime- we swap the person giving compressions back and forth so they don’t get tired. We even have a machine that does this for us.

At some point we will have tried everything. Resuscitation stops when every single member of the team agrees there is nothing more to do, or the patient’s heart will start beating again on their own.

What happens next? If the patients heart or lungs started working again, then the breathing tube is connected to a machine, and the patient is taken to intensive care.

I’ve looked after lots of patients who went through this, what we call a ‘cardiac arrest’. Some will leave the hospital, many won’t. 

The reason being is that for every second your brain is without oxygen, your brain cells are dying. We can see this on an MRI scan after a long period of ‘downtime’- time without oxygen or blood pumping leaves your brain swollen and misshapen. The chance of recovery is slimmer the worse the damage appears to be.

That all sounds very doom and gloom, but it shouldn’t. This is the very last ditch attempt to save life, and its value is inherent in the few successes we have. But they are few.

I wish everybody knew how few. The problem is our understanding of CPR as a society is based entirely on commercials and television.

A large study many years ago found that on television nearly 70% of resuscitation scenarios end with the patient waking up, and hurrahs all round. But this is far from reality. 

In the average person, the chance of that patient waking up and leaving hospital after a ‘cardiac arrest’ is around 18%. In patients with severe medical conditions, such as stroke, sepsis, or failing heart valves, the chance is about 5-10%. In end stage kidney disease or end stage cancer it can be as low as 1%. 

That is probably news to you. It certainly was to me at med school. It’s news to most of my patients and their families. 

So in summary, CPR is a brutal last ditch process that seldom works and usually has significant and lasting harms for the few that do survive. You may think I’m being grim, but this is the honest truth- please ask any medical professional. 

Now that’s why I always want to talk about CPR when people are well. When things are very hectic and somebody is very sick, it’s very hard to listen to someone saying the chance of success of CPR is low- it sounds like we are giving up. 

But we are not, we are making a plan. Good doctors like plans. We call this plan a ‘do not attempt CPR’ order, or DNACPR. It’s a very important bit of paper, kept at the front of the patients notes, usually an obvious colour like red, that states very clearly that if heart or lungs stop working we should not try to restart them, and the reasons why. 

It doesn’t change any decision about having an operation, or chemotherapy, or even using life support machines. It’s not about changing the course of treatment, it’s about making a plan for if it all goes wrong.

It might surprise you to know that a higher proportion of doctors who become unwell choose to not be resuscitated and decline treatment than the general population , choosing to die at home rather than hospital. Many doctors have their red line conditions, things they have seen that they themselves would never want to go through the treatment for, knowing the suffering involved and the likely outcomes. 

There’s a great book about medicine and death called “Being Mortal” by an American surgeon called Atul Gawande. In it he talks about five questions that everybody should ask when they contemplate the end of their lives, and he sums them up with one question “what are you fighting for?”

Reading this at home, hopefully very well, it might be hard to ever imagine what you would want if you became very sick. What would you fight for? Please think about it. 

We aren’t very good as a society about talking about death, as if the discussion of the inevitable somehow diminishes the possible. Normally my blogs finish on an abrupt punchy ending sentence, but I find the hardest conversation in my job never really ends, it just moves on,

Juniordoctorblog.com

References

Decisions relating to cardiopulmonary resuscitation 

https://www.resus.org.uk/_resources/assets/attachment/full/0/838.pdf

What Are the Chances a Hospitalized Patient Will Survive In-Hospital Arrest?

What Are the Chances a Hospitalized Patient Will Survive In-Hospital Arrest?

Being Mortal by Atul Gawande

https://www.amazon.co.uk/Being-Mortal-Medicine-What-Matters/dp/0805095152

Cardiopulmonary resuscitation on television. Miracles and misinformation.

http://www.ncbi.nlm.nih.gov/m/pubmed/8628340/?i=3&from=/19699021/related

Nolan et al “Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit.” Resuscitation. 2014 Aug;85(8):987-92.

http://www.resuscitationjournal.com/article/S0300-9572(14)00469-9/fulltext

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4 Comments

  1. Great blog, and references, as per usual!

    The latest published UK data (2011-2013) on in hospital arrests is actually a little better – 18.4% overall survival to discharge. However this drops to ~12% if >80yrs old, and 90yrs.

    Of the survivors, a surprising 97.5% had a ‘reasonable’ outcome, defined as Cerebral Performance Category 1 (‘normal life’) or 2 (‘disabled but independent’). During a 6 month cardiology rotation I saw quite a few of these patients after discharge from ITU, and it prompted me to revise my view of DNAR.

    For medics, it is worth noting that the outcome is much more likely to be positive if the initial rhythm is VF or VT (49% survival, but only 17% of arrests). If the rhythm is asystole or PEA, survival drops to 9-11%, and sadly these reflect 72% of in hospital arrests. I try to keep this in mind when running an arrest – and deciding when to stop.

    Reference:
    Nolan et al “Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit.” Resuscitation. 2014 Aug;85(8):987-92.
    http://www.resuscitationjournal.com/article/S0300-9572(14)00469-9/fulltext

  2. Good. Long overdue perspective.
    1) As a non doctor I tried long and hard to pump my father’s heart back into life in the middle of an ambulance strike when no help was coming. I was trained but he was too sick. Misled by the media portrayals, it took me years to forgive myself for this failure.
    2) Doctors need to make it clearer to well people that a DNR does not affect other simpler life saving treatments. Patients and families worry that signing these mean that doctors will give up on them earlier/ prematurely and will prevent effort based on quality of life decisions. Explaining that the DNR is simply a way of legally absolving the doctor from an unnecessary and unpleasant last ditch attempt to save a life already gone is crucial to understanding this.
    3) Truly religious people are your allies here. As a Christian I don’t want the medical profession to stop me getting to heaven thank you. Don’t get me wrong, I want to live and be cured if possible, so extreme versions of this rejection of medical intervention are not my way. Nevertheless when it is time to go, tell my relatives I am sorry but I am going to my rest now and they should let me go.
    Love and light to all

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