Chapter 5 Resuscitation - Princeton University

Chapter 5

Resuscitation

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CONTENTS

PageIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........ . ...,........167Description of Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..168

Cardiac Arrest: The Need for Resuscitation. . . . . . . . . . . . . . . . . . . . . . . .......168History of Resuscitation . . . . . . . . . . . . . . . . . . . . . . . .......................169Procedures Involved in Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...169When To Discontinue CAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...174Special Considerations in the Use of CPR for Elderly Patients . .............174Treatment Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .....,175

Utilization and Cost of Resuscitation . . . . . . . . . . . . . . . . . . . . . . . ..............175Utilization of Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........175Cost of Resuscitation. . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . ...............177Reimbursement for Resuscitation . . . . . . . . . . . . . . . . . . . . . .................177

Outcomes of Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............178Clinical Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....178Psychological Outcomes of Resuscitation . . . . . . . . . . . . . . . . . . . . . ...........181

Making Decisions About Resuscitation . . . . . . . . . . . . . . . . . . . . . ...............183Factors That Affect Physicians’ Decisions About Resuscitation . .............183The Decisionmaking Process . . . . . . . . . . . . . . . . . . . . . . . ...................185Physicians’ Directives About Resuscitation . . . . . . . . . . . . . . . . . . . . . . . ........189Resuscitation of Patients With DNR Orders by Emergency Medical Services ..193DNR Orders and Other Life-Sustaining Treatments . . . . . . . . . . . . . . . . . .. ....193

Resuscitation Policies in Hospitals and Other Institutions . ...................195Findings and Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....197Chapter 5 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ...198

BoxBox Page5-A. Majority Opinion of OTA Advisory Panel Members Regarding Informed

Consent for Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189

FiguresFigure No. Page

5-l. Administration of Basic Life Support . . . . . . . . . . . . . . . . . . . . . ............1715-2. Examples of Airway Devices Used in Advanced Cardiac Life Support ... ...l725-3. information About CPR Provided to Residents of One Nursing Home .. ....1905-4. Form Used by One Nursing Home To Obtain Resident Preferences

About CPR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................1915-5. Resuscitation Policy Adopted by One Hospital . . . . . . . . . .................196

TableTable No. Page5-1. Potential Complications Associated With Specific Resuscitation

Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............182

Chapter 5

Resuscitation

INTRODUCTION

In a person whose heart is healthy, the func-tioning of the heart is intricately timed and or-chestrated to supply the brain, lungs, body tis-sues, and organs with blood. When a person’sheart stops beating, or beats so ineffectively thatblood circulation is not sufficient to supply thebrain with oxygen and nutrients, the brain is ir-reversibly damaged within minutes, spontaneousbreathing cannot be recovered, and death ensuesquickly. Cardiopulmonary resuscitation (CPR)offers a way to reverse the imminent threat to life,

Developed only 25 years ago, CPR is a widelyapplicable means of restoring and maintainingblood circulation and breathing in a person whohas experienced a cardiac arrest. Basic CPR, thatis, external cardiac massage and mouth-to-mouthventilation, is familiar to most Americans, andmany people have been trained to perform it. Ad-vanced resuscitative techniques, such as the useof drugs and electrical shock to the heart, are lessfamiliar to most people and are almost always per-formed by trained professionals.

CPR can be applied to anyone whose heart stopsbeating. Hence, all of the roughly 2 million peo-ple who die in the United States each year—70percent of whom are elderly–are potential re-cipients. Because the alternative for a patient incardiac arrest is death, ensuring access to CPRfor all who need it is a vital public concern. Gov-ernment agencies and nonprofit organizations,such as the American Red Cross and the Amer-ican Heart Association, have developed large-scaleeducational programs to teach the basics of CPRto laypersons in local communities. Nevertheless,some elderly and other people who might bene-fit from CPR do not receive it. There are concernsthat elderly people may be less likely than youn-ger people to receive CPR because of a widespreadperception that elderly people are less likely tobenefit from it.

Somewhat paradoxically, given concerns aboutthe underuse of CPR, many observers are also con-

cerned about the possible overuse of CPR. Poorlong-term survival rates, the risk of injuries andcomplications associated with the procedures, andthe possibility of survival with severe physical andneurological impairment have prompted some ob-servers to question the appropriateness of thistechnology for certain patients, especially thosewho are terminally ill and severely debilitated.

Because of the suddenness of cardiac arrest andthe urgency of initiating treatment quickly if atall, decisions about CPR must be made momen-tarily after the arrest or at some time before anarrest occurs. In the community, cardiac arrestis usually unexpected. Paramedics, emergencymedical technicians, and trained laypersons whoperform CPR in this setting often know nothingof the patient background and are not qualifiedto assess the patient’s medical condition. In thecommunity, therefore, the presumption is gener-ally that efforts to resuscitate victims of a cardiacor respiratory arrest should be initiated automat-ically, as quickly as possible, and continued untileffective spontaneous circulation and breathingare restored, the patient is transferred to a hos-pital, or the rescuer is exhausted and unable tocontinue.

CPR is also usually initiated automatically in hos-pitals. For some patients, however, the possibil-ity of cardiac arrest is anticipated, and a decisionabout whether to administer CPR is reached inadvance. For some of these patients, a decisionis made to withhold CPR.

There are many problems in arriving at and im-plementing decisions to withhold CPR. In somecases, physicians, nurses, and other caregivers dis-agree about whether a particular patient shouldbe resuscitated. Many physicians do not discussdecisions about resuscitation or the possibility ofa Do-Not-Resuscitate (DNR) order with their pa-tients (5). DNR orders are sometimes inadequatelydocumented or not documented at all in the pa-tient’s medical chart. Some health care facilities

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168 ● Life-Sustaining Technologies and the Elderly

do not allow physicians to write DNR orders, and a formal policy about how such decisions shouldsome physicians avoid writing such orders for fear be made in order to be accredited by JCAH (67).of legal liability (43,9 o).

This chapter discusses resuscitation techniques,their use for elderly patients, and the processes

These problems have prompted many observers by which decisions about CPR are made. CPR in-to encourage adoption of clearly formulated includes a range of techniques that vary in theirstitutional policies to define procedures for mak- technological sophistication and invasiveness.ing decisions about resuscitation (14,69,71). In re- Since decisions about resuscitation also involvesponse, the Joint Commission on Accreditation of decisions about which of these techniques shouldHospitals (JCAH) has developed a standard that be used, the chapter includes some informationwill require hospitals and nursing homes to have about the various techniques.

DESCRIPTION OF RESUSCITATION

Cardiac Arrest: The Need forResuscitation

People need resuscitation as a result of eithercardiac or respiratory arrest. Cardiac arrest is thesudden unexpected cessation of heartbeat andblood pressure. It leads to loss of consciousnesswithin seconds, irreversible brain damage in aslittle as 3 minutes, and death within 4 to 15 min-utes (14)87).

Respiratory arrest is the sudden cessation of ef-fective breathing (see ch. 6). Without effectivebreathing, the blood is unable to supply adequateoxygen to the heart and brain or eliminate car-bon dioxide from body tissues. Consequently, res-piratory arrest will be followed within minutesby gradual loss of consciousness and then bycardiac arrest. Ascertaining whether a cardiac ar-rest was caused by a respiratory arrest is oftenimpossible, and virtually all cardiac arrests areaccompanied within minutes by cessation ofbreathing (14).

Although the majority of people who suffercardiac arrest are elderly, the nature and under-lying causes of their arrest vary widely. Cardiacarrest frequently results from a myocardial in-farction (loss of blood supply to the heart, com-monly known as a heart attack), but can resultfrom a variety of other conditions, including kid-ney failure, hemorrhage, and metabolic disorders.The frequencies of various causes of cardiac ar-rest cannot be precisely ascertained, because theunderlying medical conditions that result in ar-rest are often not known or not reported, andan autopsy is usually not performed (13).

In the vast majority of patients, cardiac arrestis the end point in the course of coronary arterydisease. Atherosclerosis—the accumulation offatty substances and growth of fibrous coronarytissue in the walls of arteries underlies most coro-nary artery disease and is a distinctly age-relateddisorder.

Many patients who experience cardiac arrestalso have other physiological problems that con-tribute to their arrest by placing strain on theheart. The most common problems are renal fail-ure, diabetes, pneumonia, and cancer—conditionsthat are more prevalent among elderly than young-er people (6).

Any one of various heart disturbances—arrhyth-mias, asystole, or electromechanical dissociation—may precede or initiate cardiac arrest. The mostserious of the cardiac arrhythmias (abnormalheartbeats) is ventricular fibrillation, in which theventricles of the heart twitch or beat in an un-coordinated pattern without effective contractionand cardiac output. Ventricular fibrillation occursin approximately 60 to 90 percent of cardiac ar-rests taking place in the community and in 33 to40 percent of those taking place in the hospital(14). It is also the most frequent cause of deathprior to hospital admission (66). Other arrhyth-mias associated with cardiac arrest are ventricu-lar tachycardia, which is characterized by rapidregular or only slightly irregular beats; andbradycardia, or abnormally slow heartbeats.

Asystole (the absence of electrical activity in theheart) and electromechanical dissociation (the fail-ure of a normal electrical impulse to cause con-

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Ch. 5—Ressucitation • 169

traction of the heart) cause a smaller proportionof cardiac arrests than arrhythmias (26). Arrhyth-mias, asystole, and electromechanical dissociationcan be diagnosed with the aid of an electrocar-diograph (EKG) machine, that measures the elec-trical activity of the heart and graphically depictsthe heartbeat by a series of waves.

History of Resuscitation

Attempts to resuscitate people with cardiac orrespiratory arrest began almost as early as re-corded history. Modern closed-chest cardiac mas-sage, however, was not developed until 1960,when W.B. Kouwenhoven and his associates firstapplied it (45). Prior to that time, cardiac arrestwas sometimes treated by surgically opening thepatient’s chest and directly massaging the heart.With the method developed in 1960, however, arescuer rhythmically applies pressure to the pa-tient’s sternum (breastbone); this pressure com-presses the heart and restores circulation with-out opening the patient’s chest.

Successful application of closed-chest cardiacmassage and the increased technological capabil-ity to monitor heart rhythm and to safely applyelectrical shock all contributed to the rapid andwidespread acceptance of CPR in hospitals dur-ing the 1960s and shortly thereafter by emergencyrescue teams.

It was soon discovered that the outcome of CPRdepended largely on how quickly it was initiated.In many cases where people collapsed outside ahospital, brain damage or death occurred beforean ambulance arrived. In an attempt to minimizethis time lag and to bring the ability to resuscitateout of the hospital and into the community, pub-lic agencies and nonprofit organizations developedprograms to teach the basics of CPR to commu-nity laypersons, high school students, and others(14).

Procedures Involved inResuscitation

Many people think of resuscitation as it is por-trayed on television—a bystander, a paramedic,or an emergency room physician pumping on aperson’s chest until the person either dies or isrevived. In fact, however, resuscitation consists

of a wide array of procedures, often involvingsophisticated and specialized techniques andequipment.

It was a Thursday morning, rounds were done,and the intern and medical student sat down fora quick breakfast. Suddenly, from overhead, “Codeblue . . . Code blue . . . Code blue . . . Code blue . . .!”They leapt up and ran.. . . When they arrived, resuscitation was alreadyin progress. Another medical student was rhyth-mically pushing on Mr. H’s chest, and having dif-ficulty with the position, climbed onto the bed tocontinue. A large cart loaded with drugs was nearthe door to the room, manned by two nurses.Another nurse was giving him oxygen with a maskand a bag, and an anesthesiologist was standingby, ready to put a breathing tube in Mr. H’s tra-chea. The intern periodically drew blood from thegroin and a medical student ran the blood sam-ples to the lab to measure oxygen and acid.

Above the confused chatter, shouts of “atro-pine!”, “more bicarb!”, “epinephrine!”, and othernames of drugs could be heard from the residentwho took charge of the code. The EKG machinespewed out yards of paper strips showing no heartbeat. The resident took the defibrillator paddlesseveral times, applied them to the reddened, rawchest, shouted “All clear!”) and everyone momen-tarily moved back. The lifeless body jerked witheach shock (14).

In describing the spectrum of procedures in-volved in resuscitation, it is helpful to divide theprocess into two stages: basic and advanced lifesupport. Basic life support is administered to aperson in cardiac arrest by a “rescuer,” either atrained bystander, an emergency medical techni-cian, a paramedic, a nurse (especially if initiatedin a hospital), or any other health professional.Advanced cardiac life support includes basiccardiac life support and other specialized equip-ment and techniques and is administered by para-medics or other medical personnel. In the hos-pital, advanced cardiac life support is usuallyinitiated by nurses and continued within minutesby a team of physicians.

Basic Life Support

Basic life support consists of what are referredto as the ABCs of resuscitation: Airway, Breath-

170 . Life-Sustaining Technologies and the Elderly

ing, and Circulation (see fig. 5-1).1 When a res-cuer arrives at the scene of a collapsed victim,he or she determines that the person is unrespon-sive and immediately calls for help. After position-ing the victim and ensuring that the victim’s air-way is open, the rescuer determines whether heor she is breathing by looking for chest movementand listening and feeling over the mouth forairflow.

If no breath is detected, the rescuer performsmouth-to-mouth ventilation. This involves blow-ing air into the victim’s mouth and determiningwhether the victim’s lungs are being ventilatedby watching for chest movement and hearing orfeeling the air escape during exhalation.

If a carotid pulse at the victim’s neck is absent,the rescuer begins external chest compressions.Rhythmic compressions of the sternum providecirculation to the heart, lung, brain, and otherorgans. Blood circulated to the lungs by externalchest compressions will receive enough oxygento maintain life when accompanied by properlyperformed mouth-to-mouth ventilation (64).

Advanced Cardiac Life Support

Advanced cardiac life support consists of basiclife support and the techniques and machinerythat sustain life after the immediate, manual stepsare taken. It frequently involves the use of spe-cial equipment and procedures for establishingan airway and maintaining effective ventilationand circulation.

Depending on the setting, condition of the vic-tim, and skill of the available personnel, an air-way device may be inserted through the victim’snose or mouth into the throat to keep open a pathfor air behind the tongue (see fig. 5-2). The air-way of an unconscious victim is most effectivelysecured with an endotracheal tube (a tube insertedthrough a person’s nose or mouth into the tra-chea), An endotracheal tube can protect the pa-tient’s esophagus during artificial ventilation (14).

To maintain ventilation, a bag-valve unit (a maskattached to a bag) can be used to deliver either

*Although ABC stands for Airway, Breathing, and Circulation, theAmerican Heart Association agreed in 1985 that ABC should standfor Assess, Breathe, and Circulate, as this was a more accuratedescription of what the rescuer must do (28).

room air (when the mask is placed over the mouthand nose and the bag is squeezed) or oxygen (whena source of supplemental oxygen source is at-tached to the bag-valve device). A bag-valve unitor a mechanical ventilator can be attached to anesophageal obturator airway (see fig. 5-2), or anendotracheal tube. The efficacy of ventilation isdetermined by monitoring the patient’s pulse, pu-pil reaction and size, and spontaneous respira-tions, and by periodically testing the blood for oxy-gen and carbon dioxide levels.

Supplemental oxygen is used as soon as it be-comes available. This is necessary to correct lowlevels of oxygen in a patient’s bloodstream.

Several devices can help to maintain circulation.A cardiac arrest board, placed under the patient’sback, provides a firm surface to aid in compres-sion of the chest and heart. Gas- or oxygen-pow-ered mechanical devices for external chest com-pression may be used to allow consistency in thedepth and length of compressions. These devicesare found in some emergency rooms and inten-sive care units (ICUs) and maybe used in additionto manual chest compression for cases whereprolonged resuscitative efforts are necessary.

An electrical defibrillator is used to convert ven-tricular fibrillation to a normal heart rhythm. Adefibrillator produces a high-voltage current aver-aging 4,000 volts, which is delivered over 4 to 12milliseconds via two paddles placed externally onthe patient’s chest, on either side of the heart,When left in place, the paddles can also detectthe patient’s heart rhythm and display it on a mon-itor (14). An electrical defibrillator can also be usedto convert ventricular tachycardia to a normalheart rhythm, a process called cardioversion. Likedefibrillation, cardioversion involves a brief elec-trical shock to the heart, delivered through twopaddle electrodes placed on the patient’s chest;cardioversion differs from defibrillation in thatit is timed to the heart’s electrical activity.

In adult patients who experience cardiac arrestwhile being monitored, a precordial thump (asharp, quick, blow administered over the mid-portion of the sternum within the first minuteafter cardiac arrest) may be effective in convert-ing ventricular fibrillation or ventricular tachy-cardia to a normal rhythm. Recent studies indi-cate that precordial thump should not be used

Ch. 5—Resuscitation ● 171

Figure 5-1 .—Administration of Basic Life Support

A: Initial steps of cardiopulmonary resuscitation. Top, Determining unrespon-siveness; center, calling for help; bottom, positioning the victim.B: Opening the airway. Top, airway obstruction produced by tongue and epiglottis;bottom, relief by head-tilt/chin-lift.C: Determining breathlessness.D: Rescue breathing. Top, mouth-to-mouth; bottom, mouth-to-nose,E: Determining pulselessness.F: External chest compression. Left, locating the correct hand position on thelower half of the body; right, proper position of the rescuer with shoulders directlyover the victim’s sternum and elbows locked.

D

SOURCE: National Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC). “standards and Guidelines for Cardiolmlmonary Resusci-tation (CPR) and Emergency Cardiac Care (ECC), ” Journal of the American Medical Association 255(21

63-216 0 - 87 - 5 : QL 3


Figure 5-2.—Examples of Airway Devices Used in Advanced Cardiac Life Support

A nasopharyngeal airway may be inserted through thenose to the back of the throat to keep a path for air open.

An oropharyngeal airway may be inserted through themouth to keep a path for air open.

An endotracheal tube with an inflatable cuff may be in-. . . . .serted through the nose or mouth (as pictured here) intothe trachea. It is the most effective means of securing theairway of an unconscious patient.

An esophageal obdurator airway consists of a cuffedtube that is inserted through the mouth into the esopha-gus. Airholes in the portion that is in the throat allowpassage of air into the trachea. A sealed mask preventsair leakage from the patient’s mouth and nose. When thecuff in the esophagus is inflated, air is prevented fromentering the stomach, stomach contents are preventedfrom entering the trachea and an open airway exists thatcan be used with a bag-valve device (shown) or a mechan-ical ventilator.

SOURCE: C.K. Cassel, M. Silverstein, J. La Puma, et al., “Cardiopulmonary Resuscitation in the Elderly,” prepared for the Office of Technology Assessment, U.S. Con-gress, Washington, DC, November 1985.


Photo credit: Hewlett Packard Co.

A mechanical device for external chest compression,demonstrated on a mannikin here, is sometimes usedinstead of manual chest compression, especially when

prolonged resuscitative efforts are needed.

in out-of-hospital resuscitation because of the riskthat it may thump the victim into a more malig-nant rhythm (13).

Drugs, administered either intravenously, by di-rect injections to the heart, or via endotrachealtube, play an essential role in advanced cardiaclife support. Some drugs (e.g., sodium bicarbonate)can treat life-threatening accumulations of acidcaused by lack of oxygen and retention of carbondioxide. Many drugs (e.g., epinephrine and atro-pine) influence heart rate and contractility, as wellas blood pressure. Some drugs (e.g., low doses ofdopamine) dilate blood vessels, and others (e.g.,methoxamine, phenylephrine, and high doses ofdopamine) constrict them. Other drugs (e.g., lido-caine, procainamide, and bretyllium) can correctarrhythmias in some cases. Finally, some drugscan also make a patient with ventricular fibrilla-tion more responsive to electrical shock (14).

Although not a common part of the resuscita-tion procedure itself, temporary cardiac pacingis sometimes used to regulate a patient’s heartrhythm. Temporary pacemakers are ineffectivefor some heart rhythm disturbances and tend tobe used late in resuscitation, after other therapiesprove inadequate to establish stable circulation(22). There are three basic approaches to cardiac

Photo credit: Hewlett Packard Co,

An electrical defibrillator can be used to deliver a shockto a patient’s chest to restore normal heart rhythm.

pacing during CPR: external, transthoracic, andtransvenous. External pacing uses skin electrodesto pass repetitive electrical impulses through thechest wall, to electrically stimulate the heart. Intransthoracic pacing, the physician inserts the pac-ing electrode through the patient’s chest and intothe heart muscle. In transvenous pacing, the phy-sician inserts the pacing electrode through a largevein near the patient’s collarbone and into theheart. In all three cases, the pacing electrode isconnected to an external temporary pacemaker.

Open-chest cardiac massage is the most drasticmeans of attempting to restore circulation. Thisprocedure involves surgically opening the patientchest and breaking the ribs so that the heart canbe directly massaged. It is sometimes used for pa-tients who fail to respond to standard, closed-chestmethods of resuscitation. The American HeartAssociation currently recommends using open-chest cardiac massage for patients with penetrat-ing chest injuries, severe hypothermia, cardiactamponade (where the sac surrounding the heartfills with blood or fluid), or anatomical deformitythat precludes closed-chest compression, and inpatients who suffer a cardiac arrest in the oper-ating room when their chest is already open (64).

An in-hospital resuscitation attempt may includeone, all, or any combination of the various meas-


ures described above, applied once, repeatedly,or continuously. There is no theoretical limit tothe number of times a patient can be resuscitated,although the chance of complications and inju-ries increases with every attempt. In a hospital,it is not uncommon for a patient with multiplecardiac arrests to be resuscitated repeatedly, Areview of 13,266 hospital CPR cases reported inthe medical literature from 1960 to 1980 foundthat 11 percent of CPR patients were resuscitatedtwice in one hospital stay; 2 percent were resus-citated three times; and about 1 percent wereresuscitated four times (23). One terminally ill pa-tient was reportedly resuscitated 70 times in a24-hour period (2).

For patients who survive a cardiac arrest, re-covery is rarely a simple matter of “waking up”after the resuscitation is completed. A patient’sheart rhythm may continue to be abnormal andmay require continuous monitoring, intravenousmedication, or a pacemaker. A patient may alsorequire continuous infusion of medicine to sup-port his or her blood pressure and maintain ef-fective blood flow (14).

Successfully resuscitated patients are criticallyill due to serious underlying disease, cardiac ar-rest, and the risk of recurrent cardiac arrest. Theytypically require intensive medical care and arefrequently admitted to the hospital’s ICU or coro-nary care unit (CCU) (14).

When To Discontinue CPR

There is no theoretical limit on the duration ofa resuscitation attempt. Resuscitation attemptsmay extend anywhere from a few minutes tohours, although they usually last 30 to 60 min-utes (14). Patients whose hearts begin to beat spon-taneously within 15 minutes are more likely tosurvive than patients requiring CPR for a longertime (6).

The 1980 American Heart Association Standardsfor Cardiopulmonary Resuscitation and EmergencyCardiac Care (ECC) state that CPR should be con-tinued until a patient recovers or “is found to beunresuscitable and is pronounced dead.” In gen-eral, death may be determined on the basis of:1) irreversible cessation of circulatory and respi-ratory functions, or 2) irreversible cessation of

all functions of the entire brain, including the brainstem, i.e., brain death (see ch. 2). Brain death can-not be determined before or during resuscitation,however, because 6 to 24 hours of observationare needed, along with more than one flatline EKG.Other indicators of brain death, such as lack ofpupil response and reflexes, are unreliable–particularly in elderly patients, who may have un-reactive pupils due to cataract surgery or whoare taking medications that may affect neurolog-ical responses (64). Thus, according to experts,a decision to discontinue CPR should be based ona finding of irreversible cessation of cardiovas-cular function after basic and advanced life sup-port have been properly applied (56,63,64).

Specific clinical criteria for when CPR shouldbe discontinued have been proposed, but exam-ples of the complete recovery of patients whoseresuscitation would have been terminated undersome of the proposed criteria can be cited (14).Some observers argue that no criteria would beappropriate in all cases and that the decision aboutwhen to discontinue CPR must be made on a case-by-case basis (16).

Special Considerations in the Use ofCPR for Elderly Patients

The use of some resuscitative procedures forelderly patients may be complicated by age-asso-ciated illness or physiological changes. Arthritisof the vertebrae in the neck, a condition that iscommon in elderly people can create difficultyin some of the airway maneuvers. Rheumatoidarthritis, which frequently affects the joint wherethe jaw joins the skull, can interfere with CPR bymaking the mouth difficult to open fully. More-over, age-associated illness or physiological changesmay increase the risk of resuscitation-related in-juries (see “Complications and Injuries AssociatedWith CPR” below). These age-associated problemsare not known to affect short- or long-term sur-vival following CPR (14).

In comparison to younger people, elderly peo-ple tend to have less muscle mass, more fatty tis-sue, and reduced blood flow to the liver and kid-neys (two main organs of drug elimination andmetabolism). These age-related physiological changesmay affect the way an elderly person’s body ab-


sorbs, metabolizes, distributes, and eliminatesdrugs (see ch. 9). How the drugs used in resusci-tation are affected by these changes is not known,although anecdotal evidence suggests that theremay be increased variability in response amongelderly patients. No guidelines exist for dosagesof these drugs for elderly patients.

Other age-associated problems may impedemonitoring an elderly patient’s response to a resus-citation attempt. Many elderly people have stifferarteries than younger people, making their pulsemore difficult to detect (14). Furthermore, someelderly people take medications that affect theirreflexes and other necrologic responses. Detect-ing symptoms or changes in neurological statusin such individuals can be difficult.

Although age-associated factors may complicateresuscitative procedures for some elderly patients,impede monitoring of their response to treatment,and increase the risk of resuscitation-related in-juries, there is no evidence that CPR is performeddifferently on elderly people than on younger peo-ple. Many of the procedures must be applied infull force in order for maximum benefit to beachieved. Thus, although a patient’s age may af-fect the decision to resuscitate (see section belowon “Making Decisions About Resuscitation”), oncethe decision to resuscitate has been made, the pro-cedures that are used are the same regardless ofthe patient’s age, and little is done to reduce anyadditional risks associated with advanced age (13).

Treatment Settings

Most large hospitals have the necessary equip-ment and trained personnel for both basic andadvanced cardiac life support. Some small hospi-tals do not have an ICU or CCU, and unstable resus-

citated patients maybe transferred by ambulanceor helicopter to a larger facility (14).

In nursing homes, the specialized equipment andthe personnel necessary for advanced cardiac lifesupport are frequently not available. Most nurs-ing homes do not have equipment for defibrilla-tion. Thus, nursing home residents in cardiacarrest must be transferred to a hospital by am-bulance after basic life support measures havebeen initiated. Some nursing home personnel arenot even trained in basic CPR (14,41).

In the community, resuscitation is frequentlyperformed by emergency medical technicians orparamedics attached to an ambulance rescueteam. Even if basic CPR has been started by lay-persons or medical personnel who happened tobe present at the time of a cardiac arrest, it is oftencontinued by an ambulance rescue team or occa-sionally a helicopter rescue team.

Emergency medical technicians and paramedicsare trained in basic life support techniques. Sincethe 1970s, paramedics have also been trained torecognize various arrhythmias and use a defibril-lator. Apart from the initial, standard treatmentwith external cardiac massage, incubation, intra-venous line insertion, and defibrillation, however,all medications and treatment given by paramedicsmust be given on the orders of a physician basedin an emergency room and in contact with theparamedics by radio (26).

CPR skills deteriorate rapidly if not practiced.With the exception of trained personnel who workin emergency rooms, ICUs, and CCUs, ambulanceand helicopter rescue teams, and some internsand residents, few people use CPR often enoughto maintain their skills. There are no data on howdeterioration of CPR skills affects patient survivalin any treatment setting (14).

UTILIZATION AND COST OF RESUSCITATION

Utilization of Resuscitation times the only record of a resuscitation attempt,and these notes may be difficult to discern and

For several reasons, accurate information on quantify. No government or private agency keepsthe utilization of CPR is difficult to obtain. Exist- records of CPR attempts per se. Furthermore,ing medical records systems do not necessarily reports of CPR administered in individual hospi-code CPR. Thus, the progress notes made in the tals fail to provide information on the number ofpatient’s chart by a nurse or physician are some- admissions per year or the number of bed-days

176 • Life-Sustaining Technologies and the Elderly

(days per year in which available hospital bedsare occupied by a patient) associated with CPR (14).

Nursing homes seldom have comprehensiverecords of CPR attempts, because many nursinghome residents who are resuscitated are trans-ferred by ambulance to a hospital either beforethe arrest occurs or immediately after basic lifesupport is initiated. Records of CPR attempts inthe community are neither readily available nornecessarily comparable. Moreover, the records ofemergency ambulance and helicopter rescueteams often do not include the number of peoplein the referral area, the number of ambulancecalls, or the number of emergency room visits (14).

Several other problems limit the availability ofaccurate utilization data. In many reports, the pa-tients receiving CPR are inadequately described,followup information is incomplete, and the pop-ulation at risk for CPR or from which patientswere obtained is not described or adequately re-ported. In addition, many reports of CPR includepatients with trauma, hypothermia, or cold waterdrowning—groups of patients in whom the indi-cations for CPR, utilization, and outcomes maydiffer from other groups. Elderly patients experi-encing CPR may not be uniformly distributed inthese groups (14).

As a result of these problems, there are no ac-curate figures on the number of persons who re-ceive CPR in this country. Data from the 1984National Hospital Discharge Survey, based on in-formation from the medical records of a nationalsample of patients discharged from short-stay non-Federal hospitals, indicate that 120 )000 personsof all ages received one or more of five specifiedCPR procedures ; about 73)000 (61 percent) ofthese persons were over age 65 (82). These num-bers from the National Hospital Discharge Sur-vey are much lower than estimates based on othersources on information, and they probably sig-

nificantly underestimate the number of personswho receive CPR in hospitals.3

Data from other sources suggest that 370,000to 750,000 or more persons of all ages may re-ceive CPR in hospitals each year. One basis forthis estimate is the observation that approximately700,000 persons discharged from U.S. hospitalsin 1984 had a diagnosis of acute myocardial in-farction (81); although how many of these per-sons received CPR is unknown, it is likely thatmany of them did, Moreover, many patients withdiagnoses other than myocardial infarction alsoreceive CPR. In addition, data from several studiesin individual hospitals suggest that 1 to 2 percentof patients in those hospitals received CPR (6,47).Applying this percentage to the approximately37,200)000 patients discharged from short-termnon-Federal hospitals in 1984 (81) yields a roughestimate that 372,000 to 744,000 patients may havereceived CPR in hospitals nationally.

The best available data suggest that cardiac ar-rest occurs in the community in 58 to 71 personsper 100,000 nationally (14). Yet, how many per-sons who experience cardiac arrest in the com-munity receive CPR or how many are includedin the hospital figures cited above is not known.No information about the number of persons whoreceive CPR in nursing homes or hospices isavailable.

Data compiled for OTA indicate that approxi-mately 55 percent of hospitalized patients whoreceive CPR are elderly (14). Studies in some hos-pitals have found an even higher percentage ofelderly persons among patients who received CPR.Of 294 patients who received CPR in a Boston hos-pital from 1981 to 1982, for example, only 20 per-cent were under 60 years old; 23 percent were

%lne reason the National Hospital Discharge Sumey data may un.derestimate the number of people receiving CPR in hospitals is thatthe survey collects information on up to four medical proceduresfor each patient, and CPR may not be included as one of the four

~he five procedures are conversion of cardiac rhythm; cardi- in some cases. This is especially likely since the survey form requestsopulmonary resuscitation, not otherwise specified; other electric four “surgical and diagnostic procedures” (80). Moreover, CPR at-countershock of the heart; closed-chest cardiac massage; and open- tempts may only be noted in the physician’s or nurses’ progresschest cardiac massage (80). notes and thus not easily extracted in the survey process.


60 to 70; 34 percent were 70 to 80; and 23 per-cent were over 80 (6).

If an average of 55 percent of patients who re-ceive CPR in hospitals are elderly, and 370,000to 750,000 or more persons of all ages receive CPRin hospitals, then 204,000 to 413,000 or moreelderly persons may receive CPR in hospitals. Al-though very rough, this range corresponds toother estimates based on the finding that CPR isperformed in about one-third of all hospital deaths(14). In 1984,689,000 elderly persons died in short-stay non-Federal hospitals (81); if CPR was per-formed in one-third of these hospitalizations (orabout 230,000 cases) and if death occurs in 75 to90 percent of hospital CPR attempts (as discussedbelow), then it can be estimated that 255,000 to307,000 elderly patients received CPR in hospitals.

Studies of patients receiving CPR in the com-munity indicate that their mean age is 62. Detailedage distributions are rarely reported (14), but itis likely that most of the patients receiving CPRin both settings are over age 65. More than 75percent of patients resuscitated in the communityand 70 percent of those for whom resuscitationis attempted in the hospital are men (14), prob-ably because men are more susceptible to athero-sclerosis than women.

Cost of Resuscitation

Costs associated with resuscitation include thedirect costs of procedures, equipment, and stafffor a resuscitation attempt in the community orhospital; the cost of intensive care following resus-citation; and the cost of hospitalization followingintensive care.

Some studies have analyzed the cost of commu-nity CPR by comparing program costs of estab-lishing and maintaining an emergency medicalservice with the number of lives saved. OTA isnot aware of any studies that measure the directcost of procedures, equipment, and staff for a com-munity CPR attempt. It is likely that the costs varygreatly from program to program, depending onthe range of procedures performed and equip-ment available, the proportion of volunteer to paidstaff, and the size of the service area.

In-hospital CPR may include any of several com-binations of procedures (incubation, ventilation,defibrillation, pacemaker insertion, laboratorytests, drugs), and the costs of particular resusci-tation attempts vary, depending on which proce-dures are used, the duration of each procedure,the number and type of personnel involved, andthe costs associated with each. OTA is not awareof any studies that have observed and measuredthese components during actual CPR and thenascertained their costs.

To determine the charges associated with in-hospital CPR, one would need to observe the event,record the components, determine from the hos-pital bill which of the components had, in fact,generated charges, and total these charges. OTAis not aware of any study that has done this.

Patients alive at the conclusion of a resuscita-tion attempt are in almost all cases cared for inan ICU or CCU. One published report examinedthe charges for 2,693 patients admitted to a med-ical ICU between 1977 and 1979 (78). The meanhospital bill for 41 resuscitated patients with dis-charge diagnoses of cardiopulmonary arrest whorequired active interventions was $7,235; themean stay in the ICU for these patients was 4.3days (out of a total average stay in the hospitalof 12.2 days). The hospital charges for these pa-tients generally reflected the patient’s length ofstay in the ICU, the length of the patient’s totalstay in the hospital, and the degree of interven-tion needed.

Reimbursement for Resuscitation

The Federal Government bears a large shareof the costs generated by resuscitation of elderlypeople. The reason is that virtually all individualswho are successfully resuscitated are admittedto a hospital, and hospital care for most elderlypatients is reimbursed by Medicare. Under Medi-care’s Part A (Hospital Insurance) prospective pay-ment system (PPS), each hospitalized patient isassigned to a diagnosis-related group (DRG) on ad-mission to the hospital (see ch. 2). Patients admittedin cardiac arrest maybe assigned to the DRG cat-egory for cardiac arrest (DRG 129); patients whosuffer an arrest while in the hospital, however,


have typically been assigned to a DRG other thanDRG 129 at the time of hospital admission (14).

Medicare’s hospital payment rates are higherfor some DRGs than for others, depending on theaverage cost of care associated with each diagno-sis. Anecdotal evidence suggests that hospitals trynot to assign patients to DRG 129 because theMedicare payment rate for DRG 129 is less thanfor other DRGs to which these patients may rea-sonably be assigned (14).

The Federal Government also pays for careadministered in Veterans Administration (VA) hos-

pitals. OTA has not determined the number orproportion of elderly patients resuscitated in thesehospitals or the costs of their care.

Emergency medical services that administer CPRin the community are funded from a variety ofsources, including Federal, State, and local gov-ernments and private insurers. Some communi-ties have emergency medical services that are runon a volunteer basis, without government subsi-dies, and these services usually do not charge pa-tients. Medicare Part B (Supplementary MedicalInsurance) covers some charges associated withCPR in the community.

OUTCOMES OF RESUSCITATION

Clinical Outcomes

Resuscitation can deliver a person from thebrink of death. It can restore a patient to his orher prior lifestyle within a few weeks, with onlybruises and soreness as reminders of the ordeal.Fortunate patients can resume their everydayactivities, as the following case illustrates.

charged to the ward.

Ch. 5—Resuscitation • 179

turn to a small waiting room where four famiIymembers were sitting.

After 2 hours, the doctors and nurses stoppedtrying. The chaplain reported that a daughterwanted to see her father.

Reluctantly, she was allowed in. As perople slowlyfiled out and started cleaning up, the daughterdesperately pleaded, "Dad! Come back! Comeback, Dad! It’s me, . . . come back for me, Dad!’)After she saw no response, the chaplain took herback to her family. A nurse firmly pulled the cur-tain around the bed (14).

Some patients die despite repeated resuscitationover a period of hours. A “spiraling down” effectis often seen in these patients, as they arrest andare resuscitated again and again, growing contin-ually weaker (74).

If resuscitation is unsuccessful in a hospital,death is generally accompanied by chest compres-sion, a tube in the throat, needles stuck in the groinand elsewhere, and possibly several high-energyelectrical shocks. In extreme cases, a needle is in-serted directly into the heart or the chest is openedand ribs broken to directly massage the heart. Itis not known how the dying person perceives thisprocess, if at all, or whether the process increasesthe suffering associated with death. Most patientswho die during CPR are unconscious (4). In thevery few studies asking survivors about theirmemories, most have no memory of any part ofthe resuscitation process, although, as discussedbelow, some say they would not want it done again(6,30).

Long lingering death after CPR appears to bethe publicized exception rather than the commonoccurrence (6). Most patients who die followingresuscitation do so within the first few days.

The medical literature on outcomes of resusci-tation exhibits several methodologic problems inaddition to the limitations already described forutilization data. The greatest problem in compar-ing available studies is that different studies usedifferent definitions of success (e.g., restorationof a spontaneous pulse, restoration of circulation,or remaining alive for 24 hours) and different defi-nitions of survival (e.g., living until discharge fromhospital, for 1 month, for 6 months, for a year,or more). The way these terms are defined deter-

mines, to a large extent, the outcomes that arereported (14).

Although widely varying success rates havebeen reported, on average, one-third to one-halfof CPR attempts in hospitals are initially success-ful. For patients with cardiac arrhythmias, the ini-tial success rate is better-about two thirds of CPRattempts with these patients initially succeed. Notall patients who are successfully resuscitated re-cover enough to be discharged from the hospital,however. Only about one-third to one-half of thosewho are successfully resuscitated (approximately10 to 25 percent of those for whom CPR is at-tempted) survive long enough to be dischargedfrom the hospital.’

Very little information is available about the out-comes of CPR in nursing homes. One study of1,918 persons admitted to a New York State nurs-ing home over an 8-year period found that only32 persons (2 percent) received CPR in the facil-ity. Of these, 9 persons (28 percent) survived morethan 24 hours, and 5 of the 9 (16 percent of allthose who received CPR) were still alive 30 dayslater (42).

The hospital admission rate for patients resus-citated in the community is a practical measureof the initial success rate of community CPR. Usingthis measure, several studies indicate an averagesuccess rate of 35 percent (range 23 to 44 per-cent) for community CPR (14). Among personswho are successfully resuscitated in the commu-nity and hospitalized, the percentage who recoverenough to be discharged from the hospital variesgreatly, depending on the cause of their cardiacarrest, whether the cardiac arrests were wit-nessed, how soon after cardiac arrest CPR wasinitiated, and whether paramedic care or onlybasic life support was provided (21).

Long-term survival of patients resuscitated inany setting is rare (14,69). Recurrent suddencardiac death is the most likely eventual cause ofdeath in those initially surviving cardiac arrest.

4These overall averages are based on reviews of the literature bythe President’s Commission for the Study of Ethical Problems inMedicine and Biomedical and Behavioral Research (69) and by Cas-sel, et al. (14).


Factors That Affect the ClinicalOutcome of Resuscitation

A patient’s underlying diagnosis and severity ofillness are major determinants of resuscitation out-come (6,15,30). One study of 294 patients resus-citated in a Boston hospital found, for example,that although 14 percent of the patients survivedto leave the hospital, no patients who had metas-tatic cancer or pneumonia and only 2 percent ofpatients with renal failure survived to leave thehospital (6). Patients with multiple diseases usu-ally fail to recover from cardiac arrest despiteprolonged CPR and eventually die through fail-ure of one organ system or another (57).

A patient’s level of functioning prior to cardiacarrest is a predictor of outcome of resuscitation(6,15). One study found that only 4 percent of pa-tients who had been homebound prior to theircardiac arrest survived cardiac arrest and CPR,compared to 27 percent of patients who had beenactive outside the home before their cardiac ar-rest (6).

The nature of a patient’s cardiac arrest is anotherstrong predictor of outcome. Patients with ven-tricular fibrillation are more likely to survive thanpatients with asystole or electromechanical dis-sociation (6,21). Patients with ventricular tachy-cardia have intermediate success rates (89).

Some CPR procedures are not effective whencertain heart irregularities are present. Defibril-lation, for example, is an effective means of re-storing heartbeat for patients with ventricular fib-rillation but not for patients with asystole (37).Likewise, pacing can be effective for asystole butis ineffective in treating ventricular fibrillation andelectromechanical dissociation (72).

The time between occurrence of the cardiac ar-rest and initiation of resuscitative measures—“down time”–greatly influences the patient’schance of recovery. In the past decade, at leastnine studies have found that survival followingcardiac arrest is related to early initiation of CPR(21).

Long-term survival in patients resuscitated af-ter a delay of more than 5 minutes has been doc-umented, but the chance of brain damage increases

(16,21). The 1974 American Heart Associationstandards stated:

The technique of CPR is most effective whenstarted immediately after cardiac arrest. If cardiacarrest has persisted for more than 10 minutes,CPR is unlikely to restore the victim to his prear-rest central nervous system status (62).5

Duration of the resuscitative effort is also astrong predictor of outcome. As duration in-creases, survival rates decrease. Resuscitation ef-forts lasting longer than 30 minutes are usuallyunsuccessful (6,16,57), Some patients have recov-ered completely following 2 to 3 hours of resus-citative effort, but such cases are usually associ-ated with hypothermia in drowning or with drugoverdose (14).

The relationship of outcome to the number ofresuscitative attempts that a patient receives dur-ing a single episode has not been determined. Thepoorer outcomes observed with more resuscita-tion attempts in some studies may be due to thelonger total duration that naturally accompaniesa greater number of attempts.

A patient’s age is not a good predictor of theoutcome of resuscitation (6,14,15,30,31,32,48,68).Some studies show no significant difference be-tween success rates for elderly and younger pa-tients (see, e.g., references 6 and 15). Other studies(e.g., reference 30) show that elderly patients asa group have somewhat poorer outcomes thanyounger patients but that the poorer outcomesin elderly patients reflect the higher prevalenceof multiple diseases in these patients. Althoughthe likelihood of multiple diseases increases withage, any particular older individual may not beaffected. Thus, ail these studies support the con-clusion that a patient’s age alone is not a goodpredictor of resuscitation outcome.

Within the elderly population, the initial suc-cess rate for CPR does not decrease significantlyin older age groups (12,14)32). One study of 1,345persons who received CPR in the communityfound no significant difference in the percentage

5The brain may be viable for a longer period of time in specialcases of barbiturate and sedative overdose, hypothermia, anddrownings.


of patients in four age groups over 65 (ages 65to 69; 70 to 74; 75 to 79; and 80 to 99) who wereresuscitated and hospitalized. The percentage ofsuccessfully resuscitated patients who recoveredenough to be discharged from the hospital, how-ever, decreased significantly with age—from 15percent of patients aged 65 to 69 to only 8 per-cent of those aged 80 to 99 (79). Thus althoughpatients in the very old age groups were success-fully resuscitated as often as patients aged 65 to69, patients in the very old age groups were lesslikely to survive to be discharged from the hospital.

The same study (79) found that cardiac arrestwas witnessed more often for elderly patients.Yet bystanders provided CPR prior to the arrivalof paramedics more often for younger patients.

Use of Other Life-SustainingTechnolog ies Fo l lowing CPR

Following resuscitation, many patients requirenot only admission to an ICU or CCU and extendedhospitalization but also invasive hemodynamicmonitoring, prolonged mechanical ventilation, ordialysis. In one study, 78 percent of the patientsadmitted to hospital ICUs for a cardiac arrest re-quired such a major intervention (18).

The life-sustaining technology most likely to berequired for patients who survive resuscitationis mechanical ventilation (14). Respiratory func-tion is often inadequate immediately after success-ful resuscitation, and recovery to independentbreathing may take days or weeks. There is someevidence that outcome for patients receiving ven-tilatory assistance following CPR is not as goodas that of other patients (88), probably becausepatients requiring such assistance tend to be moreill in general than patients who do not need suchassistance.

Complications and InjuriesAssociated With CPR

Resuscitation can be accompanied by a wide ar-ray of complications and potential injuries thatmay be long-lasting and even life-threatening, par-ticularly for individuals who are already seriouslyill.

Brain damage is the result of cardiac arrest andthe consequent interruption in the supply of oxy-

gen to the patient’s brain. Some people think ofit as a complication of resuscitation, and, in fact,delayed initiation of CPR and inadequately per-formed CPR increase the risk of brain damage inpersons who are successfully resuscitated.

Each of the various basic and advanced life sup-port procedures carries its own set of risks andpotential complications. The major problems thatmay be encountered as a result of procedures usedduring resuscitation are summarized in table 5-1.

The most common resuscitation-related injuriesinclude rib fracture, collapsed lung, rupturedstomach, and broken teeth. In survivors of resus-citation, these problems can cause pain, makebreathing difficult, impede weaning from a me-chanical ventilator, or produce other problemsthat complicate postresuscitative care.

Little information is available about the inci-dence of resuscitation-related injuries, but onestudy of 63 survivors of cardiopulmonary arrestfound such injuries in over 25 percent of the pa-tients (10). Elderly patients, because they are morelikely to have osteoporosis (brittle bones), are atan increased risk of fractures, but no age-specificdata are available to indicate whether such inju-ries are more common in elderly survivors ofresuscitation than younger ones (14).

Psychological Outcomes ofResuscitation

In the aftermath of a cardiac arrest, many sur-vivors experience psychological repercussions.Several of the resuscitated patients in a study atBeth Israel Hospital in Boston reported that thehardest part of their subsequent hospitalizationwas adjusting to “feeling sick” and dealing withtheir new loss of independence (6). Depressionwas present in most of these patients at the timeof their discharge, although it tended to resolveitself within 6 months. Every resuscitated patientin this study, regardless of age, reported some de-crease in daily activities. In many cases, the fearof another arrest led patients to regulate their dailylives and limit their activities to ensure immedi-ate access to medical care.

Surveys of patients’ attitudes towards resusci-tation indicate that some survivors do not wishto be resuscitated again, although they had not

.

182 . Life-Sustaining Technologies and the Elder/y

Table 5=1.-Potential Complications AssociatedWith Specific Resuscitation Procedures

Basic life uppoti procedures:● regurgitation● aspiration• gastric distension (with mouth-to-mouth)● rib fracture● collapsed lung● ruptured stomach● spinal cord compressionTracheal Intubation:● insertion of the tube into the esophagus● trauma to the trachea or esophagus● damage to the vocal cords● narrowing of the trachea following tube removalDefiberllation:● myocardial necrosis (damage to heart muscle)

Pracordial thump:● a more dangerous heart rhythmDrugs:● Sodium bicarbonate (in excess)

—alkalosis—sodium and water overload—paradoxical cerebral spinal fluid acidosis

● Atropine—ventricular fibrillation—tachycardia—increased oxygen demand by the heart with increased

heart rate● Calcium chloride

—intracellular damageTemporary cardiac pacemakers:● External pacers

—severe muscle contractions—local tissue burns

● Transvenous pacers—local trauma—infection—laceration of the heart muscle—blood clots—ventricular arrhythmias

● Transthoracic pacers—collapsed lung—heart injury, including laceration—laceration of blood vessels

SOURCES: C.K. Caaael, M.D. SIlversteln, J. LaPuma, et al., “Cardiopulmona~Resuscltatton in the Elderly,” prepared for the Office of TechnologyAssessment, U.S. Congress, Washington, DC, November 1985; R.H.Falk, L. Jacobs, A. Sinclair, et al., “External Noninvaaive Cardiac Pac-ing in Out-of-Hospital Cardiac Arrest,” Cr/t/ca/ Care Med/c/ne 11(10):779-782, 1983; and J.R. Roberts and Ml. Greenberg, “EmergencyTransthoracic Pacemaker,” Anna/s of Emergency Medicine 10(11):800-812, 1981.

been opposed to their first resuscitation and theyare content with their present quality of life. Onestudy found that when 38 survivors of resuscita-tion were asked if they would choose to be resus-citated in the future if it were necessary, 21 (55percent) said yes, 16 (42 percent) said no, and 1was ambivalent. At a followup 6 months later,three patients had changed their minds: two pa-tients no longer desired resuscitation and one saidshe would choose it (6).

Resistance to a second resuscitation seems tobe found particularly among older survivors. Astudy in a hospital in Nuremberg, Germany, foundthat older survivors of resuscitation tended to bemore negative about resuscitation than youngersurvivors (30). Eighteen 6-month survivors, all ofwhom were satisfied with their current life andstate of health, were asked about their opinionstoward resuscitation. All of the nine survivors un-der age 60 said they would agree to another resus-citation, but seven of the nine survivors over age60 said they would not (the other two had no opin-ion). Similarly, six of the nine survivors under age60 thought it reasonable to resuscitate aged per-sons under all circumstances, and three thoughtit reasonable only with certain indications. In con-trast, seven of the nine survivors over age 60thought it reasonable to resuscitate aged personsonly on certain indications, and two had noopinion.

Ch. 5—Resuscitation . 183

MAKING DECISIONS ABOUT RESUSCITATION

In the first 15 years following the developmentof CPR, physicians tended to implement both basicand advanced life support measures without hesi-tation whenever the need arose. Over time, how-ever, there has been a growing recognition amongphysicians and others of problems associated withresuscitation, particularly the low chance of suc-cess and the risk of debilitating or life-threateningcomplications.

In 1976, the New England Journal of Medicinepublished two articles on withholding life support,particularly resuscitation, from terminally ill pa-tients (20,70). An accompanying editorial entitled“Terminating Life Support: Out of the Closet” (29)praised the two articles for making public the“open secret” that resuscitation (and other life-sustaining treatments to a lesser degree) were be-ing withheld or withdrawn from some terminallyill patients.

Since then, criteria and procedures for decid-ing to withhold CPR have been widely analyzedand debated. Although debate about these criteriaand procedures continues, it is now generally ac-cepted that CPR is not an appropriate treatmentfor every patient in cardiac arrest. A strong pre-sumption in favor of resuscitation remains, never-theless. As one observer has noted:

[CPR] is the only medical intervention that canbe performed by nonphysicians without a physi-cian’s order; a physician’s order is required onlyif CPR is to be withheld, even in the patient home(90).

In the case of persons who experience unex-pected cardiac arrest in the community and inthe case of most patients in hospitals and otherhealth care facilities, it is assumed that CPR shouldbe attempted, because the alternative for the in-dividual is certain death. For some patients, how-ever, CPR is withheld. Withholding of CPR mayoccur as the result of a unilateral decision madeby a physician at the time of the person’s cardiacarrest. Alternatively, CPR maybe withheld on the

basis of a prior decision by the physician some-times in consultation with other health care pro-viders, the patient, and/or the patient’s family. Insuch cases, a DNR order—a directive to withholdCPR—may be written in the patient’s medicalchart.

This section discusses the factors that affect phy-sicians’ decisions to withhold CPR, the usual roleof physicians, nurses, and patients and their fam-ilies in the decisionmaking process, what is knownabout the current use of DNR orders, and prob-lems associated with their use. The same factorsare associated with physicians’ decisions to with-hold CPR as reflected in research on: 1) their statedattitudes about which types of patients should notreceive CPR; 2) their actual decisions to withholdCPR, especially in hospitals; and 3) their decisionsabout which patients should have a DNR order.Data from all three sources are summarizedbelow.

Factors That Affect Physicians’Decisions About Resuscitation

Many factors enter into physicians’ decisionsabout whether resuscitation is appropriate for agiven patient. First and foremost are indicatorsof the potential for successful outcome. Physiciansare not obliged to provide futile or useless treat-ment, and a decision not to resuscitate is gener-ally considered appropriate when CPR would befutile (51). Thus, a patient’s underlying diagnosisand other determinants of resuscitation efficacy(see “Outcomes of Resuscitation”) are importantconsiderations in physicians’ decisions to withholdCPR.

The presence of a terminal illness in a patientis frequently mentioned by physicians as a rea-son for withholding CPR. In the Portland, Ore-gon area, 87 percent of 78 emergency medicinephysicians surveyed said they would stop CPR ona patient in the end stage of a terminal disease(16). Similarly, cancer was the most common diag-


nosis of patients in one Boston hospital who diedwithout receiving resuscitative measures (6), andseveral studies have shown that patients with can-cer are more likely than other patients to havea DNR order (25,73).

Severity of illness is another frequently men-tioned factor in physicians’ decisions about resus-citation. Many physicians believe that resuscitationshould be withheld from patients with multipleor severe diseases that are chronic, progressive,or irreversible (15,40). Some physicians argue thatalthough CPR is technically possible in such pa-tients, it is right to exclude patients with chronic,progressive, disabling diseases who are highly de-pendent on others (32).

Some physicians believe that it is appropriateto withhold CPR from some patients who havesevere illnesses but who are not terminally ill. Onestudy of DNR orders in a medical ICU found thata patient severity of illness was the most impor-tant predictor of his or her DNR status, but over60 percent of patients with DNR orders did nothave a diagnosis of terminal illness (91). Likewise,in a community hospital, 40 percent of those withDNR orders did not have a terminal illness docu-mented in their medical record (49).

Another factor that is considered in resuscita-tion decisions is “downtime.” The Portland studyof emergency medicine physicians found that 44percent said they would cease CPR if it had beeninitiated in the community more than 10 minutesafter the patient went into cardiac arrest (16).Down time is associated with brain damage, asdiscussed earlier, and one expert in resuscitationhas cautioned that “litigation is more likely to fol-low when the patient survives (a cardiac arrest)with permanent brain damage than when the pa-tient dies” (56).

In addition to factors that have been shown toaffect the medical outcome of resuscitation, suchas severity of illness and “downtime,” several otherfactors that do not affect the medical outcome ofresuscitation often play an important role in phy-sicians’ attitudes and decisions about its use. Onesuch factor is the patient’s mental status. Whenpresented with case descriptions of one dementedand one mentally retarded patient in cardiac ar-rest and two cognitively normal patients also in

cardiac arrest, 63 physicians in a Philadelphia in-ternal medicine residency program said that theywould be less likely to initiate CPR on the de-mented and mentally retarded patients than thecognitively normal patients (27). Likewise, the Port-land study found that 54 percent of the 78 physi-cians stated that they would cease CPR if theylearned that a patient had a known severe mentalimpairment, such as dementia or mental retarda-tion (16).

A patient’s mental status may also influence phy-sicians’ decisions about whether a patient shouldhave a DNR order. In one Boston hospital, 49 per-cent of patients who were given a DNR order hadabnormal mental status (i.e., they were comatoseor disoriented), compared to only 15 percent ofa control group of patients who did not have ab-normal mental status (73). In another hospital, ter-minally ill patients who were mentally alert weregenerally not given a DNR order (36).

Another factor that influences resuscitation de-cisions is a patient’s residence in a nursing home.One study found that the knowledge that a pa-tient in cardiac arrest had been admitted to thehospital from a nursing home was enough to dis-courage some physicians from continuing CPR;18 percent of 78 emergency room physicians sur-veyed in Oregon said they would cease CPR if thepatient had been transferred from a nursing home(16). Another study found that patients who wereadmitted from a nursing home were three timesmore likely to be given a DNR order than a matchedcontrol group of patients who were not admittedfrom a nursing home (73).

Finally, although research shows that patientage alone does not alter the outcome of resuscita-tion and many authors recommend against theuse of age as a factor in decisions about CPR(40,55,59), in practice, age plays a significant rolein these decisions (15,19). Gordon and Hurowitzdescribed a bias against elderly patients in physi-cians’ decisions about whether to administer CPR:

For younger patients, a physician’s decision notto resuscitate is usually made after conscious de-liberation. This is not always so for the elderly,and yet, most physicians do not resuscitate manyof their elderly patients. It is not clear at preciselywhat level the decision to resuscitate is made, but


in the majority of elderly deaths, CPR attemptshave not been carried out (31).

A survey of physicians in a Philadelphia inter-nal medicine residency program found that a pa-tient’s age influenced their attitudes about whetherto administer CPR. When presented with twohypothetical cases, one of a 32-year-old patientwith a pulmonary embolism and the other of a98-year-old patient with the same condition, allof the 63 physicians responding to the surveystated that they would be much more likely toresuscitate the younger patient than the older one.The physicians’ disinclination to resuscitate olderpatients was also evident, although less strongly,when the age of the older patient was changedto 64 (27).

There is some evidence that the patient’s ageis a predictor of DNR designation. A study of ICUpatients in a Cleveland hospital found the aver-age age of the 71 patients with such orders was66 years, while the average age of the 435 patientswithout DNR orders was less than 58 years (91).This difference could not be solely attributed tothe facts that DNR patients are usually seriouslyill and that the incidence of serious illness increaseswith age, because 166 seriously ill patients with-out DNR orders had an average age of less than61 years.

The rationale for the use of a patient’s age asa factor in decisions about administering CPR isnot clear. Some physicians may not resuscitateelderly patients particularly in instances of un-observed cardiac arrest or when the effort is notpromptly successful because of their perceptionsthat CPR may simply prolong the process of dy-ing and that many elderly patients fear death lessthan prolonged dying or dependence on others.According to one physician:

The vast majority of my patients over 65 tellme that 1) they do not dread death, and hope thattheirs will be sudden; and 2) they do fear incar-ceration in a nursing home or total dependenceon others (3).

Another physician, who asked 153 decisionallycapable elderly (aged 66 to 98 years) nursing homeresidents whether they wanted to receive CPR inthe event of a cardiac arrest found that 77 resi-dents (50 percent) did not want CPR; 11 residents

(7 percent) did want it; 64 residents (42 percent)wanted their physician to choose at the time; andI did not respond. Considering the large numberof residents who did not want CPR, that physi-cian concluded:

Although age alone does not preclude candidacyfor CPR, the changed attitudes and values of oldpeople are at least as germane to case selectionas are any other consideration. As a group, theelderly tend to be realistic and to often recog-nize . . . that sometimes “death is the best life hasto offer” (86).

The Decisionmaking Process

A patient’s physician has the authority to makea decision about initiating or withholding CPR, buthe or she may not be available at the time the de-cision must be made. Many other individuals mayalso be involved in the decisionmaking process.The urgency of the event and the involvementof many people with different points of view anddifferent information about the patient can cre-ate a complex and sometimes chaotic situation,as illustrated in the following case:

old, is brought into the emer-

‘that he suffered a heart attackand was not breathing for an unknown periodo f t _ t a t e d b y p a r a m e d i c s .

. . .

Approximately 1 hour later a "Code blue” iscalled. Mr. R has suffered a cardiac arrest. By thetime Ms. C responds to the code, the code team


Potential Participants in DecisionsAbout Resuscitation

In general, only a physician may decide to with-hold CPR. Emergency rescue teams have stand-ing orders to initiate CPR as quickly as possible.In hospitals, staff members are generally requiredto initiate CPR unless there is a physician’s ordernot to resuscitate a particular patient.

In hospitals that have staff physicians, residents,and interns, these individuals frequently make de-cisions about resuscitation. A study in one hospi-tal found, for example, that the patient’s physi-cian was involved in decisions to withhold CPRin only 39 percent of cases, and residents and in-terns made the decision in the other cases (80).

Nurses cannot legally make decisions aboutresuscitation, yet research indicates that theyoften have strong feelings about whether theirpatients should be resuscitated. It is not known

how often nurses are involved in such decisions.One study found that nursing involvement in de-cisions about DNR orders had been documentedin only 10 percent of cases; however, nurses hadplayed an active role in assessing the patient’s andfamily’s attitudes about the patient’s condition andtreatment and encouraging open discussion be-tween the patient and the physician about the pa-tient’s resuscitation status (7).

In the event of a sudden and unexpected cardiacarrest, a patient cannot participate in the deci-sion about whether to resuscitate, and the involve-ment of the patient’s family is severely limited bytime constraints. In the great majority of cases,however, advance deliberation is possible, and pa-tients and families can be involved in decision-making.

Patient and Family Involvement inDecisions About Resuscitation

Physicians once made decisions about whetherto resuscitate patients behind closed doors, pater-nalistically protecting their patients from what thephysician believed would be upsetting for the pa-tient. Recent legal developments and changing atti-tudes of the public as well as many physicians sup-port the rights of decisionally capable adults tobe informed about their medical condition andto participate in decisions about their medical care,including resuscitation (1,64).

Yet patients are not always consulted about theirdesire for CPR. The findings of one study suggestthat although many physicians believe that patientparticipation in resuscitation decisions is impor-tant, they often do not act accordingly (5). Theresearchers interviewed 157 physicians involvedin the care of 154 patients who had been resusci-tated (24 of the patients survived). Almost all thephysicians said they believed that patients shouldparticipate in decisions about resuscitation, butonly 10 percent of the physicians had actually dis-cussed resuscitation with their patients prior tothe patient’s cardiac arrest (s).

Almost all the physicians interviewed thoughtthey knew what their patients would want, buttheir opinions correlated only weakly with thepreferences expressed by the 24 surviving pa-tients, particularly the patients who did not want


to be resuscitated. For example, although 8 of the24 patients stated that they had not wanted CPR,only 1 of the 16 physicians caring for these 8 pa-tients was aware of this preference; 10 of the phy-sicians thought their patients wanted CPR; 3thought their patients were ambivalent, and 2 hadno opinion (5).

Other studies indicate that patients are usuallynot involved in decisions about DNR orders. Astudy of 95 patients with DNR orders in a Bostonhospital found that consent for the DNR orderhad been given by the patient in only 18 percentof the cases. The family had given consent in 66percent of the cases (73). A study of DNR ordersin one ICU found that patients’ wishes were listedas a reason for the decision in only 15 percentof the cases. There were no written justificationsfor the DNR orders in 42 percent of the cases,but in cases where there was documentation, itmore commonly included poor prognosis (59 per-cent) or the perception of poor quality of life (24percent) than patient preferences (9 I).

At the time decisions about DNR orders aremade for them, many patients of all ages are notdecisionally capable. In one ICU, 55 percent ofpatients with DNR orders were unable to partici-pate in decisionmaking because of coma or re-duced consciousness (92). In another hospital, 76percent of patients for whom a DNR order waswritten were unable to participate in the decisionas a result of preexisting dementia, newly acquiredcoma, or other conditions that caused reducedconsciousness or cognitive impairment. Only 11percent of the patients, however, had been toocognitively impaired to participate in decisionmak-ing at the time of their admission to the hospital (7).

Even for patients who are decisionally capable,physicians may consult the family rather than thepatient. A study of DNR orders in three Texasteaching hospitals found that the patient and/orfamily was involved in 83 percent of decisions notto resuscitate; in at least 20 percent of these cases,the decision was discussed with the family, notthe patient, even though the patient was consid-ered decisionally capable (25). As one ethicist hasnoted, failure to involve decisionally capable pa-tients in a decision to withhold CPR in the eventof a cardiac arrest is a serious ethical problem (85).

Decisions to resuscitate maybe discussed withpatients and families even less often than deci-sions not to resuscitate (90). In the three Texasteaching hospitals mentioned above, researchersfound that physicians’ decisions that patientsshould be resuscitated in the event of cardiac ar-rest had been discussed with only 22 percent ofthe affected patients or their families (25).

Some physicians refrain from discussing resus-citation with their patients in order to protectthem or because they feel it is unnecessary tobring up the issue (5). Some physicians also be-lieve that patients will initiate a discussion aboutresuscitation if they wish. Many patients, how-ever, believe that physicians would rather not dis-cuss treatment options, particularly if the discus-sion might lead to an emotional scene, might takea lot of time, or could be interpreted as implyinglack of trust (l). In addition, many physicians havedifficulty discussing issues related to death or dy-ing (see ch. 10). As one physician has noted, find-ing the “right time” for such discussions is alsodifficult:

Despite all arguments favoring open discussion,it is difficult to broach the issues of death andtreatment limitation with a patient or family. Notime seems like the right time. When patients arerelatively healthy, we do not want to upset themneedlessly; when they are terribly sick, we do notwant to upset them further. If we wait too long,they may become incompetent. There is no sim-ple answer to this question of timing. In general,it is easier if discussions about these issues havebeen part of the ongoing physician/patient rela-tionship, instead of being precipitated for the firsttime by a crisis (90).

Some physicians and other health care providersare more reluctant to discuss treatment optionswith older patients than younger ones. This maybe because they assume that older patients pre-fer to have treatment decisions made for them;because they assume that older patients will notunderstand the discussion; or because older pa-tients are more likely than younger ones to havehearing or speech impairments that may inter-fere with communication. Thus, elderly peoplemay be less likely than younger people to be in-volved in decisions about their treatment.

188 ● Life-Sustaining Technologies and the Elder/y

Disagreement Among Participants inDecisions About Resuscitation

Even when patients and their families are con-sulted, decisions about resuscitation are not eas-ily made. A consensual decisionmaking processthat involves many people may remove the fullburden of the decision from the shoulders of thephysician, but can also make the process evenmore difficult.

Family members may disagree about the appro-priate treatment, as the following case illustrates:

A patient’s physician and staff physicians, resi-dents, and interns may also disagree about whetherthe patient should be resuscitated. OTA is notaware of any research on the frequency of suchdisagreements when a decision about resuscita-tion is made without advance deliberation at thetime of a patient’s cardiac arrest. One study ofDNR orders at three Texas hospitals, however,found that staff physicians disagreed with the de-cisions about DNR made by patients’ physiciansfor 43 (6 percent) of the 758 patients: only 1 ofthe 43 disagreements involved a patient who hada DNR order; the remainder involved patientswhom staff physicians thought should have a DNRorder but did not (25).

Sometimes nurses disagree with patients’ phy-sicians and with staff physicians, residents, andinterns about the appropriate treatment decisionfor a particular patient. Although the patient’s phy-sician is ultimately responsible for the decision,several observers argue that physicians shouldcarefully consider decisions about a patient’s DNRstatus that meet with persistent, thoughtful dis-agreement from staff nurses. They point out thatnurses sometimes have a greater awareness ofpatient and family emotional responses and treat-ment preferences than the physician (50,90).

In some instances, a physician may disagree withthe patient or family about whether resuscitationshould be provided. Some physicians who disagreewith a patient’s or family’s directive not to resus-citate override that directive. A physician may dothis when a patient is not terminally ill or has fewserious conditions. In such cases, the physicianacts in what he or she considers the patient’s “bestinterest,” reasoning, for example, that “resuscita-tion is not what the patient meant when she saidthat she wanted no extraordinary measures taken,”or that “the patient was just depressed when hesigned the DNR order and will be thankful later”(4,11).

Conversely, some physicians override a patient’sor family’s wishes for treatment when they be-lieve that their demands for resuscitation are un-reasonable or that treatment will not benefit thepatient (51). unilateral decisions by physicians notto provide CPR when the patient or family hasrequested it are controversial, however, and in-crease risk of litigation. To avoid these problems,some physicians may give a verbal order not toresuscitate the patient but fail to document theorder in the patient’s medical record (52).

Obtaining Informed Consentfor Resuscitation

Informed consent for resuscitation is usually notobtained in any treatment setting, partly becauseof the strong general presumption that all patientswho experience cardiac arrest should be resusci-tated unless there is a physician’s order to with-hold CPR. Some observers have noted that the lackof a requirement for informed consent for resus-citation supports a lack of communication be-tween physicians and patients (75). At least mini-mal discussion about many other invasive medicalprocedures is ensured because informed consentis required. Resuscitation differs from these pro-cedures in that its need is sudden and often un-anticipated. Yet advance deliberation is theoreti-cally possible in virtually all cases.

There is currently much debate about thedesirability of requiring informed consent forresuscitation at some point during a patient’s hos-pitalization. Some observers favor such a require-ment as a means of ensuring prior discussion ofthe resuscitation decision. According to one phy-sician:


It would seem that the time has arrived whenall patients should have an opportunity to expresstheir desire for or against resuscitation on rou-tine admission to the hospital. The use of a stand-ard written form for patients to consider on ad-mission might force a more thorough discussionof the issue between patient and physician (75).

In a meeting of the advisory panel for this OTAassessment, the majority of panelists favored re-quiring informed consent for resuscitation afterthe first 24 hours of hospitalization for patientsfor whom the issue is appropriate (see box 5-A).

Other observers believe that requiring informedconsent for resuscitation is unrealistic and inad-visable. They argue that requiring physicians todiscuss resuscitation with all hospitalized patientswho may die “would provoke unnecessary anxi-ety” (15).

Trying to ascertain a patient’s preference aboutresuscitation at the time of hospital admission maybe inappropriate for several reasons. At the timethey enter the hospital, patients are often underemotional stress and may not be able to fully andproperly consider a resuscitation decision. They

•

medical teamcision.

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may fail to fully understand the consequences oftheir decision or to anticipate all circumstancesin which cardiac arrest might occur. Temporarydepression at the time of admission to a hospitalmight color some patients’ decisions. Finally, thevitally important decision about whether or notto resuscitate might get buried amidst the numer-ous questions patients must answer and formsthey must sign on hospital admission.

Some nursing homes solicit residents’ prefer-ences about resuscitation at the time of admis-sion or during their stay in the facility. The writ-ten information about CPR provided to residentsby one such facility and the form used to obtainresidents’ responses are illustrated in figures 5-3and 5-4. The blank spaces at the bottom of theform used to obtain residents’ responses are forchanges in residents’ previously expressed wishes.When a resident of the nursing home is hospi-talized, a photocopy of the form expressing hisor her preference about resuscitation is sent tothe hospital with other medical information (86).

physicians ) Directives AboutResuscitation

The Use of DNR Orders

The use of DNR orders has at least two widelyunderstood goals: 1) to ensure that physicians whoare most familiar with a particular patient decideon the appropriateness of resuscitation attemptsbefore such attempts are needed and without thestress induced by a sudden arrest; and 2) to en-courage physicians to consult with patients, orwith the families of decisionally incapable patients,to determine their wishes concerning furthertreatment (25).

Some observers suggest that the following pro-cedures should be followed by physicians issu-ing DNR orders (59):

●

●

●

The physician fully evaluates the patient’smedical condition.The physician, with the rest of the health careteam, determines the appropriateness of aDNR order for the patient.When the patient is decisionally capable, theDNR decision is reached between the patientand physician.

-


● When the patient is decisionally incapable,the physician consults family members orother surrogate decisionmakers.

● If the patient or family members disagree withthe DNR order, it is not implemented.

● Once the DNR decision is made, the physi-cian discusses its meaning with the otherhealth care personnel involved in the patient’scare (59).

There are no national data on the percentageof patients with DNR orders. Data from individ-ual hospitals indicate the percentage varies amongdifferent hospitals. Recent studies in hospitals inSan Francisco and Boston have found that 3 to4 percent of all patients have DNR orders (7,49,52)73), whereas 9 percent of patients in threeTexas hospitals had DNR orders (25).

Figure 5.3.—information About CPR Provided to Residents of One Nursing Home

THE MATHER HOME1615 Hinman Avenue

Evanston, Illinois, 60201

To Our Residents:

In all procedures, whether performed on our Health Center or in the EvanstonHospital, you--the patient--will have final governance over what is done for you and youwill be given full disclosure of all facts involved to enable you to make the right decision.

The objective of all examinations and treatments is your well being and comfort.Therefore, we do not subscribe to heroic measures to sustain life if such measures wouldcause great suffering and if life would be of poor quality afterwards. Neither, on theother hand, can we do less than support you humanely in a lingering illness.

This brings us to the final consideration: cardiac arrest. It happens in infinitelyvaried circumstances: inappropriately, in the young, with all other systems intact;appropriately, in our own age group, as a result of general failure of interdependentsystems. Since cardiac arrest stops all pumping action of the heart, cardio-pulmonaryresuscitation is instituted at once in all hospitalized patients because the brain will nottolerate more than four minutes of no circulation without permanent damage. Cardio-pulmonary resuscitation, or CPR, is a manual maneuver which rhythmically compressesthe heart between the front and back of the chest by pushing the breast bone down. [nthis way, circulation can be maintained until electroshock can be arranged to start theheart up again.

The problem in age is that the ribs are no longer elastic, but brittle, so that thepushing required to squeeze the heart effectively regularly breaks ribs. These sometimeslacerate the lung as well. Only rarely, at this predictable cost, can we actually achieveour objective of happy survival.

Our request that you give the attached statement careful consideration followsestablished policies. You may wish to discuss the issue with your family and/or with theHome’s physician. Please complete the form, insert it in the enclosed envelope, seal theenvelope and place it in the slot box in our Mail Room.

AdministrationSOURCE: The Mather Home, Evanston, IL.


Figure 5-4.— Form Used by One Nursing Home To Obtain Resident Preferences About CPR

THE MATHER HOME1615 Hinman Avenue

Evanston, Illinois, 60201

To: The Mather Medical Department

Subject: PATIENT’S WISH REGARDING CARDIO-PULMONARY RESUSCITATION(supplemental form)

I have been fully informed about Cardio-Pulmonary Resuscitation, its techniques,its objectives, its successes and failures.

I further understand that in the event of cardiac arrest from any cause in thehospital, I will automatically and immediately be given CPR unless this has been ruledout in advance by my attending physician, who must be guided by my prior informeddecision.

Based upon my consideration of this information, I elect the option indicated below:

1.

2.

3.

I do not wish CPR under any circumstance.

I do wish CPR to be performed in any situation of cardiac arrest regardless ofthe attendant circumstances.

I wish my physician to make the decision regarding the propriety of CPR atwhatever time it may become a contingency, and give the force of my wish tohis decision.

Date Option Signature

SOURCE: The Mather Home, Evanston, IL.


Studies in 14 ICUs across the country found thatthe frequency of DNR orders varied from less than1 percent to 14 percent of all patients (91,92).These variations were not explained by differ-ences in patient characteristics in the differentICUs and may instead reflect differences in phy-sician attitudes toward aggressive treatment (92).

The use of DNR orders is beginning in a fewnursing homes (see “Resuscitation Policies in Hos-pitals and Other Institutions”) but is not as com-mon in nursing homes as in hospitals. For manynursing home residents, the critical decision withregard to resuscitation is often a decision not tohospitalize the resident, thus limiting treatmentto that available in the nursing home (8).

Agreement between physicians and family mem-bers about a patient’s DNR status maybe difficultto reach because many family members fear thata patient with DNR orders will be neglected bythe medical staff, DNR policies commonly statethat the administration of other forms of careshould be independent of the decision to with-hold resuscitation. The withdrawal of caregiversfrom patients with DNR orders has been clinicallyobserved, however, and may be a particular prob-lem for elderly patients (46).

Disaggregating Decisions AboutTreatment: DNI and DNT Orders

Patients and their families often come into con-tact with the health care system during periodsof personal crisis. At such times, they may requestthat “no heroics” be provided or, conversely, that“everything possible” be done. These broad direc-tives are open to a variety of interpretations byhealth care providers, and patients and familiessometimes fail to consider or to understand theimplications of their requests.

Resuscitation can be the starting point for pro-longed dependence on other technologies suchas mechanical ventilation. The patient and/or fam-ily members who request “no heroics” may feelquite differently about a fairly simple procedurelike external cardiac massage than they feel aboutmore invasive techniques like open-chest massage,defibrillation, and pacing. Yet there is no way todistinguish among life-sustaining technologieswhen wishes are expressed in global terms suchas those just noted. This ambiguity demonstratesthe need for clear definition of terms.

A DNR directive can itself be made clearer bythe disaggregation into a variety of more specificdirectives. With partial codes, CPR is initiated, butdrugs are not administered, incubation is not per-formed, or resuscitation is stopped after a pre-determined period of time (51). Do-Not-Treat(DNT) orders prohibit all active treatment, whileDo-Not -Incubate (DNI) orders state that the rangeof resuscitative efforts short of incubation maybe performed. The decision of whether or not tointubate may in the mind of the patient or familybe separate from the decision to administer ex-ternal chest compressions (25), and some patientsmay desire a partial code.

“Show Codes)) and “Slow Codes))

Sometimes, rather than issue a written DNR or-der, a physician may verbally direct staff to per-form a few resuscitative procedures to reassurethe patient’s family that “everything was done”(51, but with the intention of letting the patientdie. This has been called a “show code.” A similarmethod that is used to reassure the family is a“slow code”—the physician may direct health carepersonnel on call to “Walk, not run, if the patientarrests.” Or the physician may ask the nurses topage him or her personally rather than alert theCPR team over the loudspeaker, A slow code in-creases the chances of permanent brain damage,because in order to be effective, CPR must be in-stituted with all possible speed (14).

Slow and show codes are considered by manyto be dishonest and entirely inconsistent withestablished ethical principles. Moreover, they canplace caregivers in legal jeopardy (43). Yet theyare frequently applied when an explicit DNR or-der cannot be written, either because it has notyet been discussed with the family or becausethere is disagreement among the family, the pa-tient, and the physician. For patients who are notterminally ill, for example, a DNR decision is oftendifficult to make. The phenomena of slow andshow codes has prompted some observers to callfor continuing education of caregivers and otherstrategies to discourage these practices (65,71,90).

Legal Concerns About Physicians’Directives To Withhold Resuscitation

No caregiver has ever been found liable for aproperly derived and documented DNR order, andcaregivers can be held liable for battery if they


resuscitate a patient against the patient’s wishes.Yet there remains a wide range of beliefs regard-ing what the law requires (43).

Some health care professionals are reluctant towithhold resuscitation even with a DNR order be-cause of fear of legal liability—especially if thereis not unanimous agreement with the DNR orderamong all the concerned parties. This fear existsdespite one court’s ruling that the appropriate-ness of a DNR order is a question “to be answeredin accordance with sound medical practice in con-sideration of the individual patient’s conditionsand prognosis” (38).

Caregivers are also uncertain about withhold-ing CPR from decisionalIy incapable patients withno available guardian to authorize a DNR order.In rare cases, they seek recourse in the courts,but they more commonly resuscitate or performa “slow code.”

In some cases, physicians who have issued DNRorders without the knowledge of patients or theirfamilies have tried to protect themselves from lia-bility by leaving no record of the DNR order. In1984, a special grand jury investigating a deathin a Queens, New York hospital found that thehospital had been using an informal “purple dot”system to denote which of the patients were notto be resuscitated in the event of a cardiac arrest.Nurses recorded DNR orders for hospital staff byaffixing purple decals, available in the hospital giftshop, to their index cards. The nursing cards in-cluding the purple decals were destroyed afterthe patients died. The system insured both secrecy,since neither the patients nor their families wereaware of the DNR decision, and lack of accounta-bility for the decision (76).

In recent years, nurses have become increas-ingly concerned about their own legal responsi-bility and liability, and nurses may be particularlyafraid of legal repercussions in decisions aboutresuscitation when all parties to the decision donot agree. Nurses are often first to respond to acardiac arrest. If a DNR order has been writtenwithout the knowledge of or against the wishesof the patient or family, the nurse may bearresponsibility for withholding CPR. Conversely,if a nurse knows the patient does not want resus-citation but the physician has not written a DNR

order, the nurse could still be in legal jeopardyfor initiating resuscitation. An even more diffi-cult situation occurs when the physician gives anoral order not to resuscitate the patient, but doesnot write a formal order in the chart. Nurses whofollow such oral orders have no documentationthat the physician told them not to resuscitate andhence they risk legal liability. For these reasons,many nurses favor the establishment of explicitinstitutional policies for decisions about resusci-tation (43,44).

Resuscitation of Patients With DNROrders by Emergency Medical

Services

The use of CPR by ambulance and other emer-gency medical personnel for nursing home andhospice patients who have DNR orders is an is-sue of growing concern. Emergency medical per-sonnel are usually unfamiliar with a particularpatient’s medical background and treatment planand usually have standing orders to resuscitateall patients in cardiac arrest (58).

In order to avoid resuscitation of patients withDNR orders, many hospices now instruct theirclients not to activate the emergency medical serv-ices system (i.e., call an ambulance) for an appar-ently terminal event. This approach denies pa-tients relief from severe, potentially reversiblesymptoms, however, and denies families assistancewith difficult events (35).

One county in Minnesota has developed a pol-icy allowing paramedics and emergency physi-cians to honor orders in nursing home recordsnot to resuscitate or intubate residents (58). Thepatient’s physician is required to document thedirective in the medical record and to update itperiodically. The patient with a DNR or DNI or-der remains eligible for hospitalization and otheremergency care.

DNR Orders and Other Life-Sustaining Treatments

Many experts agree that a DNR order shouldnot imply that other treatments will be withheldor withdrawn, and they point out that patientswith DNR orders may still be appropriate candi-


dates for mechanical ventilation, dialysis, and evensurgery and chemotherapy (24,40,59,64,69,91).Research and anecdotal evidence suggest, how-ever, that such treatments are frequently with-held or withdrawn from patients with DNR orders.

The type of care provided to patients with DNRorders varies in different hospitals. A study in oneICU found that treatments such as blood transfu-sions, dialysis, and mechanical ventilation werewithheld from 68 percent of patients with DNRorders and withdrawn from 40 percent of patientswith DNR orders (92). A study in another ICUfound, however, that life-sustaining treatmentswere not routinely withheld or withdrawn aftera DNR order was written. Ninety-eight percentof patients receiving mechanical ventilation priorto the DNR order continued to receive it after-wards. Likewise, vasoactive drugs and intravenousantibiotics were withheld from less than 25 per-cent of patients after a DNR order was written (91).

Another study that was not restricted to ICUpatients found that life-sustaining treatments werewithheld or withdrawn from 28 percent of pa-tients after DNR orders were written. Within thisgroup, mechanical ventilation was withdrawnfrom all the patients who had been receiving itbefore the DNR order was written; dialysis waswithdrawn from 40 percent of patients who hadbeen receiving it and withheld from 60 percentof patients for whom it would otherwise have beenprovided; and intravenous fluids and antibioticswere withheld or withdrawn from about half ofthe patients. These changes in level of care werediscussed with the family in 71 percent of thecases, the patient in 8 percent of the cases, andneither in 21 percent (7).

Finally, a study of patients in a community hos-pital (49) found that resource use, as measuredby hospital charges, was reduced significantly af-ter DNR orders were written. On average, chargesfor patients with DNR orders dropped $97 on theday after the DNR order was written. On subse-quent days, hospital charges were, on average,$100 less per day for patients with DNR ordersthan for patients without DNR orders—a differ-ence of 40 percent of median daily charges (ex-cluding room rate) for all patients. The level ofcare provided for patients with DNR orders var-ied widely however:

Six percent received no medical care after DNRorders, that is, they died immediately after DNRdesignation, Twenty-five percent received hospice-type care, including pain control, counseling fromthe hospital’s Human Support Team, and/or psy-chosocial support from the nursing staff. Moder-ate levels of care were given to 27 percent of thepatients; this type of care included the adminis-tration of antibiotics for sepsis, fever, or pneumo-nia and medication for a chronic condition. Highlevels of care characterized the treatment givento 29 percent of patients; patients with multiplemedical problems receiving numerous medica-tions were likely to fall into this group. Finally,12 percent of patients received maximal levels oftherapy after DNR designation, including renal di-alysis, ventilator assistance, hyperalimentation,major surgical procedures, and/or invasive cardiacmonitoring (49).

There was no relationship between patient ageand the type of care provided after the DNR des-ignation (49).

Although the kinds of treatment provided fol-lowing DNR designation vary greatly among pa-tients, several studies indicate that the kinds ofcare to be provided or withheld are not usuallydocumented by the physician in the patient’s med-ical record. As a result, nurses and others whoare caring for such patients may be confusedabout what treatments are to be provided (7,25,49).

In addition, anecdotal evidence suggests thatMedicare payment for hospitalization and somemedical treatments is sometimes denied for pa-tients with DNR orders. The Association of Com-munity Cancer Centers is currently surveying itsmember institutions concerning any experiencewith Medicare payment denials for terminal pa-tients, particularly those with DNR orders (77)

Finally, although most experts agree that otherlife-sustaining treatments should not be automat-ically withheld or withdrawn when a DNR orderis written, some have questioned the meaning ofa DNR order when other aggressive life-sustainingtreatments are continued (49,91). In this context,it is interesting to note that data from three studiesshow that many hospital patients with DNR orders(27, 39, and 51 percent, respectively) left the hos-pital alive (7,49,73).

Ch.. 5—Resuscitation ● 195

RESUSCITATION POLICIES IN HOSPITALS ANDOTHER INSTITUTIONS

With varied and often conflicting attitudes aboutthe role and responsibilities of the patient’s phy-sician, staff physicians, nurses, patients, and fam-ilies, and, overall, about the goal of treatment it-self, there has developed a need for mechanismsby which decisions about resuscitation can bemade. In response to this need, some hospitals,nursing homes, and hospices have developed in-stitutional guidelines and policies governing de-cisions about resuscitation. One hospital’s guide-lines for decisions about resuscitation are shownin figure 5-5.

One survey of hospitals in five MidwesternStates found that over 60 percent either had orwere in the process of developing a formal resus-citation policy. Two variables—institutional sizeand the presence of an ethics committee—wereassociated with the presence of resuscitation pol-icies in the responding hospitals (61).

A 1986 survey conducted by the Joint Commis-sion on Accreditation of Hospitals (JCAH) foundthat 57 percent of hospitals, 20 percent of nurs-ing homes, and 43 percent of hospices respond-ing to the survey had formal resuscitatation policies(39). Larger institutions, institutions accredited byJCAH, and institutions with an ethics committeewere more likely than other institutions to havea formal resuscitation policy. One resuscition pol-icy identified in the survey was instituted in 1969,but the great majority had been put into effectsince 1983 (53).

Hospital, nursing home, and hospice resuscita-tion policies have become more sophisticated andsystematic in the past few years. Terms such as“competent patient,“ “incompetent patient,” and“guardian” are defined. The responsibilities of thepatient, family members, physicians, nurses, andother medical personnel are clearly delineated.Even the meaning of resuscitation itself has beenmore specifically defined (14).

Many institutional resuscitation policies includestatements about the following:

. resuscitation as a standing order, to be initi-ated unless there is a physician’s order to thecontrary;

●

●

●

●

●

●

●

●

●

who may write DNR orders;the medical conditions that justify a DNRorder;procedures for determining the patient’s deci-sionmaking capacity;procedures for ascertaining the patient’swishes;the role of the family, close associates, andother persons in the decisionmaking process;the scope of the DNR order (e.g., a DNR or-der does not limit other forms of medical in-tervention);documentation of the DNR order in the pa-tient’s record;discussion of the DNR order with involvedstaff; andprocedures for periodic review (e.g., subjectto daily review, maybe revoked at any time)(14,53).

Beyond the common elements listed above, exist-ing resuscitation policies show considerable diver-sity, reflecting the characteristics of different in-stitutions.

According to the JCAH survey, the most com-mon problems encountered by institutions in im-plementing resuscitation policies were conflictsbetween physicians and nurses about DNR ordersand the need for continuing education of staffabout the policy (53). A third problem reportedby the institutions was the difficulty of definingthe relationship between DNR orders and othertreatments. This problem has been identified bymany observers (25,33)60) (see also previous sec-tion on “DNR Oders and Other Life-SustainingTreatments”). Although some facilities have de-veloped policies to define what treatments shouldbe provided for patients with DNR orders, mosthave not. The JCAH survey found that among in-stitutions with formal resuscitation policies, only17 percent of hospitals, 7 percent of nursinghomes, and 12 percent of hospices had policiesaddressing the withholding or withdrawing ofother treatments (53).

In general, national medical, hospital, nursinghome, and hospice associations have not devel-oped specific guidelines for institutional resusci-


tation policies. Some have issued general state- Cardiopulmonary resuscitation is not indicated inments on the use of CPR, however. The following certain situations, such as in cases of terminal,statement by the 1973 National Conference on irreversible illness where death is not unexpected

Standards for Cardiopulmonary Resuscitation and or where prolonged cardiac arrest dictates the

Emergency Cardiac Care is an example. futility of resuscitation efforts. Resuscitation inthese circumstances may represent a positive vio-

The purpose of cardiopulmonary resuscitation lation of an individual’s right to die with dignityis the prevention of sudden, unexpected death. (62).

Figure 5-5.—Resuscitation Policy Adopted by One Hospital

SOURCE: Beth Israel Hospital, Boston, MA, Jan. 1, 1984.

Ch. 5—/?esuscitation ● 797

In addition, many national associations supporttheir member institutions by providing informa-tion or facilitating communication among institu-tions about resuscitation policies.

The VA has developed standards to guide VAfacilities in formulating resuscitation policies tai-lored to the population they serve. The standardsacknowledge that:

. . . there will be those cases where, in the exer-cise of sound medical judgment, a licensed physi-cian who knows the patient may appropriatelygive an instruction not to institute resuscitationat the bedside of a patient who has just experi-enced an arrest” (83).

The most recent VA statement recognizes the var-iation among States in statutory and case law rele-vant to decisions about life-sustaining treatmentand requires VA facilities to develop resuscitationpolicies that are consistent with both existing Statelaw and applicable VA standards (84).

In 1983, the President’sStudy of Ethical Problems

Commission for thein Medicine and Bio-

FINDINGS AND

CPR involves various procedures that can beclassified as either basic or advanced cardiac lifesupport. The basic procedures, external cardiacmassage and mouth-to-mouth ventilation, can beadministered anywhere, by any person trainedin the techniques. The more advanced proceduresmust be performed by trained health professionals,usually in a hospital where the equipment is read-ily available.

Since its development in 1960, the tremendouslife-saving potential of this technology has becomewidely recognized, for at some point in the dyingprocess of every person, the heart stops beatingand resuscitation can be applied. Indeed, resusci-tation is used for thousands of people each year,the majority of whom are elderly.

Specific data for utilization or cost of resuscita-tion are not available. Rough estimates indicatethat 204,000 to 413,000 elderly persons may re-ceive CPR in hospitals annually, and an additionalbut unknown number receive CPR in the com-

medical and Behavioral Research recommendedthat “in order to be accredited, hospitals shouldbe required to have a general policy regardingresuscitation” (69). In response to this recommen-dation and widespread agreement about the needfor such policies, JCAH has developed a new stand-ard for accreditation of hospitals and nursinghomes that will require each institution to havea policy for decisions about resuscitation. The newJCAH standard will be implemented in 1988 (67).

The proposed JCAH standard does not requirehospitals and nursing homes to address the rela-tionship between DNR orders and other life-sus-taining treatments that might be provided for thepatient. Such a requirement could be a logical nextstep. In the meantime, national hospital and nurs-ing home associations might encourage their mem-ber facilities to adopt institutional policies that re-quire explicit consideration and documentationof what other treatments are to be provided orwithheld once a DNR order has been written.

IMPLICATIONS

munity. Research is needed to develop accurateutilization and cost figures.

In contrast, the outcomes of resuscitation havebeen extensively studied. On average, one-thirdto one-half of resuscitation attempts in hospitalsare initially successful. Among those patients whoare successfully resuscitated in the hospital, one-third to one-half (about 10 to 25 percent of all thosewho receive CPR) initially recover enough to bedischarged from the hospital.

Various complications and injuries may accom-pany resuscitation. The most common complica-tions are injuries such as rib fractures, collapsedlungs, and ruptured stomachs. Some survivors suf-fer permanent brain damage or need mechanicalventilation, dialysis, and/or invasive hemodynamicmonitoring.

Factors that influence resuscitation outcomesinclude the patient’s underlying physical condi-tion, the nature of the cardiac arrest, the elapsedtime between cardiac arrest and initiation of resus-


citative efforts, and duration of the resuscitationattempt. The patient’s age alone is not a goodpredictor of resuscitation outcomes.

Several age-related conditions, such as osteopo-rosis, cataracts, arthritis, and altered metabolism,however, may increase risk of complications. Avail-able evidence indicates that resuscitation is notperformed differently with elderly patients thanwith younger ones. More research is needed toassess any added risks associated with age.

More is known about how decisions about resus-citation are made than about how decisions aboutother life-sustaining technologies are made. Al-though resuscitation decisions vary from individ-ual to individual, factors that are frequently in-volved include the clinical indicators of the chanceof success, as well as the patient’s mental status.The patient’s age is sometimes a factor in deci-sions about resuscitation, although age alone isnot a good predictor of outcome.

It is now widely accepted that resuscitation isnot appropriate for every patient. When cardiacarrest occurs unexpectedly and/or there has beenno advance deliberation of the appropriatenessof resuscitation, CPR is almost always attemptedbecause the alternative for the patient is death.For patients in hospital and other settings, deci-sions about whether to initiate CPR are sometimesconsidered in advance of a patient’s cardiac ar-

rest. Although the bias towards attempting resus-citation is very strong, there is increasing use inthese institutions of DNR orders-directives towithhold CPR.

Problems with DNR orders include lack of pa-tient and family involvement in decisions abouttheir use, lack of documentation of the orders,and disagreements among physicians, nurses, andfamily members about whether a particular pa-tient should have a DNR order. In order to ad-dress these problems, some hospitals, nursinghomes, and hospices have developed formal resus-citation policies, but many have not.

JCAH has recently issued new standards thatrequire hospitals and nursing homes to developresuscitation policies in order to be accredited.Such policies will help resolve some of the prob-lems in existing decisionmaking procedures andmay provide some legal protection for physicians,nurses, and others who adhere to them. At theleast, such policies will clarify for health careprofessionals, patients, and families how decisionsabout whether to provide CPR will be made ineach facility. National hospital, nursing home, andhospice associations and physicians’ and nurses’associations have a role in providing expert ad-vice and consultation to facilities and individualprofessionals involved in the development of in-stitutional resuscitation policies.

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