Aging, Allow Natural Death, AND, chaplaincy, CPR, DNR, Do Not Resuscitate, emergency room doctor, health care, Jewish medical Ethics, medical ethics, NY Times, pastoral care, paula span, research, science, scientific research, spiritual care
One of the most difficult conversations to have with people is the discussion of whether to opt for DNR (Do Not Resuscitate), or as it becoming more common to call it AND (Allow Natural Death). As most people are aware on some level, the notion that CPR can be successful is predicated on media distortion. In reality, as the below article discusses, the chances of discharge from a hospital after CPR is low and becomes less likely as we age. I think it is important that we all remember this information, for while making that choice for ourselves or a loved one might be challenging, we need to have perspective on the reality.
PAULA SPANJustin Sullivan/Getty Images
What are the odds of survival for people whose hearts stop — not in a hospital, but out in the world — and who receive cardiopulmonary resuscitation, at least long enough to get to a hospital and then to be discharged from it?
Most of us have watched too much television — one minute the heroic medical worker pumps the victim’s chest and grabs the defibrillator paddles and yells “Clear!,” and in the next scene the victim is sitting up, chatting with detectives — to have any realistic idea.
It’s not an easy question to answer anyway, depending as it does on whether someone sees the patient collapse or whether it happens unobserved, on how long it takes before CPR starts and then how long before skilled medical personnel can begin the rest of the advanced cardiac drill (drugs, defibrillation, airways). The particular type of cardiac arrhythmia involved matters; so do other illnesses the patient may have, and how frail she is.
But as a ballpark figure, let’s say that maintaining a heart rate by chest compression until the cavalry arrives succeeds no more than 20 percent of the time. That estimate comes from Dr. David John, an emergency room doctor in Massachusetts and Connecticut for 20 years and the former geriatrics chairman of the American College of Emergency Physicians. Some studies put the proportion much lower, some higher.
If we’re surprised, let me add that referring to TV shows was no joke. In 1996, The New England Journal of Medicine published an analysis of three popular series: “ER,” “Chicago Hope” and “Rescue 911.” Two-thirds of those victims survived to discharge after CPR, possibly because in Teeveeland, cardiac arrests occur most often in children, teenagers and young adults wounded by gunshots or injured in auto crashes. In reality, most people whose hearts stop are elderly people with cardiac disease.
And for old people in the real world, the odds of successful CPR seem worse — though not as much worse as one might think. One study following about 2,600 out-of-hospital cardiac arrests over four and a half years in Oakland County, Mich., found that patients in their 40s and 50s had the highest rate of successful resuscitation: 10 percent. The statistics got only slightly worse with each decade: 8.1 percent successful resuscitation for patients in their 60s, 7.1 percent in their 70s. After 80, though, only 3.3 percent survived to hospital discharge.
In King County, Wash., where a surveillance system tracks every out-of-hospital cardiac arrest, University of Washington researchers focused on the very elderly and found that 9.4 percent of octogenarians and 4.4 percent of nonagenarians survived after CPR, compared with 19.4 percent of younger patients. All three groups did much better if they had the heart arrhythmias known as ventricular fibrillation or ventricular tachycardia, but those occurred more commonly in younger people, so survival among those in their 80s and 90s improved to only 24 percent and 17 percent, respectively. (This study included CPR done by bystanders, paramedics or both, which might have affected the results.)
The authors of these and other studies take pains to say that age alone is not a basis for doing CPR or withholding it. You could be the diabetic 53-year-old who dies or the (rarer) robust 83-year-old with the “right” heart arrhythmia who pulls through. Moreover, the wider distribution of automated external defibrillators in airports and malls and the ubiquity of cellphones — both can mean less time between collapse and help — may have improved results since these studies were done.
But since older people are much more likely to have other diseases and health problems — and since merely getting discharged from the hospital doesn’t tell us much about what your subsequent life is like (can you speak? walk? remember?) or where you live it or for how long — I think CPR raises a dilemma for older adults.
CPR doesn’t work very often, and it works slightly less often on those beyond 70 and considerably less often at more advanced ages. Do you agree to it, for yourself or your relative? Call 911 and let the emergency technicians, the people most commonly performing CPR and defibrillation these days, do their best? Or do you say no?
It’s such a deeply personal decision that it’s not surprising that even those on the front lines of emergency medicine can come down differently. Tomorrow, I’ll pass along what a couple of very seasoned ER doctors had to say, and what we decided in my own family.
Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”