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The Realities of Advanced Medical Interventions
Micki Jackson , coordinator
Approximately 90 minutes with time for ?’s later-
Handouts : WAHA, list of medical terms used
Make Your Wishes Known
Koala and Cathy – ICU RNs
CPR- Cardipulmonary Resuscitation Mechanical Ventilation- Respirator
(breathing support) Pressors-Intravenous drugs to support blood
pressure Artificial Nutrition- feeding tubes Dialysis-kidney function
Advanced Medical Interventions
In the US 540,000 people experience cardiac arrest each year-most out of hospital- Circulation 2013
Age range- birth to 100+ years 5-15% survive to hospital discharge What do these survivors have in common
and how are they very different? Our survival rates have improved- EMS,CPR,
medications, devices
Reality Check- Life is 100% Fatal
200,000 in-hospital cardiac arrests -American Heart Assoc
18.3 % survive to discharge
No improvements since 1992 BUT……
Percentage discharged to home is less Discharges to hospice (17x) and long term care
facilities (6x) increased
Cardiac Arrest in Hospital-better #’s?
CPR- cardiopulmonary resuscitation “The heart is compressed to a depth of 2
inches by squeezing it between the rib cage and the spine”
Blood is squeezed out of the heart and pumped to the brain and other organs
Who gets CPR? Who gets good CPR AED’s-automatic external defibrillator- not
all heart rhythms are “shockable”
Advanced Life Support Examined
Effective CPR
CPR
Lucas Device
CPR aftermath
died during
died before discharge
died after discharge
alive at 1 yr
49%
35%
7%
10%
Elderly (65+) CPR Survivors-JAMA Internal Medicine 2013
Cerebral Performance Categories
Survivors: Functional scoring-
Age % of survivors with good neuro -logical function or minimal deficits on discharge (could be CPC1 or 2)
<70 12.6%
70-74 10.2 %
75-79 8.6%
80-84 7.6%
>-85 4.5%
Age Matters….
CPR Works but age matters
Reason for hospital admit
% survival to discharge with “better” outcome (CPC 1)
Major trauma- broken bones
6%
Acute stroke- bleed or clot 3.7%
Cancer-tumors 5.2%
Blood infection-sepsis 3.6%
Liver function poor 4.4%
Admitted from a skilled nursing facility
3.2%
Kidney function poor 6.4%
Pneumonia 5.2%
History matters…
Mechanical Ventilation advanced airway/breathing support
Ventilator suctioning
Tracheostomy- temporary or
permanent?
Medicines given intravenously
Pressors- Blood pressure support adrenaline- fight or flight
Kidney injury- dialysis
Nutritional support
Your doctor Your nurse Your family
Perception is everything…
Really Advanced Medical Interventions
Joan Rivers 81 yrs oldRoutine upper GI scope exam because she had voice
changes and indigestion
She stopped breathing during sedation for the procedure and suffered brain damage from lack of oxygen
Quote from the ME…… “resulted from a predictable complication of medical therapy”
ALL elective and emergent procedures have predictable complications- do you understand the real risk?
Patient Scenarios Examined
Elderly man in Florida
Where will you live? New medicines and treatmentsCommunication and memory
Who will take care of your daily needsWho is left at home if you can’t be thereIt’s expensive and who pays- do you have LTC
insurance?What will your Medicare cover?What about Medicaid?
Life after Survival
Deciding not to have CPR (“DNR” means do not resuscitate) does NOT mean no care-patients may still want life support treatments in a hospital or ICU.
Antibiotics, IV fluids and other medical treatments are available
Nurses help patients stay comfortable- you get the care you need and WANT
What if I don’t want “Everything”
“Doctors have a hard time with this”
Palliative Care- a team that focuses on providing specialized care to relieve the symptoms, pain and stress of serious illness.
Hospice -support in the community
Comfort Care- final hours/days in hospital
Other Choices
Your Life- Your Choices
?
Time for Questions…..
“We need to stop treating CPR as something special -ie a default action; as something that is a genuine medical option even when it’s therapeutic potential is remote”
“It’s the only thing in medicine that we treat this way, like it’s a sort of human right, as opposed to a complicated medical procedural intervention with indications and contraindication, good reasons to do it, and good reasons not to….”
“Hospital QI compartments must start looking at questions of whether there was an indication for CPR in the first place and if not—why was it offered/why didn’t the patient have a DNR order/why weren’t people discussing this with the patient/family?”
do things need to change?--Editorial in Journal of Palliative Medicine
