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Here is part two from the previous post as the author of the article below continues discussing CPR in the elderly.
I’ll confess I was startled to learn, after too many episodes of “ER,” how rarely cardiopulmonary resuscitation succeeds in restarting someone’s heart. The rate of long-term success is probably about 20 percent, said Dr. David John, former geriatrics chairman of the American College of Emergency Physicians. “When your heart stops, it’s really hard to get it back,” he said.
“Long-term success” has a particular definition here: It means that a patient, after cardiac arrest, survives long enough to be discharged from a hospital. Studies often don’t report what happens thereafter. But even that modest kind of success occurs less frequently in older people who receive CPR, declining slightly for those in their 70s, then more steeply for those in their 80s and 90s, several studies show. And like any other medical intervention, CPR involves its own risks.
This can all seem very abstract to a healthy middle-aged person with no history of heart problems. But as people age, and increasingly cope with multiple diseases and frailty, the issue grows more urgent and more complex. The blunt question: Should a frail, elderly person receive CPR?
In his 33 years as an emergency room doctor — mostly in hospitals in Maryland and now at Christian Hospital in St. Louis — Dr. David Davis estimates he has resuscitated 600 people. CPR, he likes to point out, was developed during the Korean War to help wounded soldiers — otherwise healthy young men — stay alive until they reached field hospitals. Doing chest compressions on fragile old people disturbs him.
“It is violent,” Dr. Davis told me in an interview. “If you don’t do it hard enough, you can’t move any blood.” But if you do thrust hard enough, “you’re going to break the ribs and maybe the sternum.”
Afterward, he worries about the few old people he may have saved, about whether they will ever recover strength and function after days or weeks in intensive care.
“If older people and their families knew all that was involved, the manipulation, the tubes, the drugs and the low chances for a good outcome, they’d opt for comfort care instead,” Dr. Davis said. He’s 66, and tattooed on his own chest is an informal advance directive: “Shock Thrice,” meaning that after three attempts at defibrillation, the team should stop resuscitation and allow him to die.
(A recent editorial in The Journal of General Internal Medicine, by the way, argues that a do-not-resuscitate tattoo isn’t actually an effective way to communicate end-of-life wishes; an advance directive or POLST – physician orders for life-sustaining treatment – works better.)
But Dr. John, a 20-year emergency medicine veteran now practicing at Johnson Memorial Medical Center in Stafford Springs, Conn., argues that the risk of brain damage with CPR is small and can arise in patients of any age. He sees the pain of broken ribs as a small price for staying alive.
“If you’re a reasonably healthy and functioning older adult, there’s no reason to withhold CPR,” Dr. John said. He’s 58, and he said, “If I’m in a supermarket and I go down, and there’s an external defibrillator and someone grabs it and shocks me within two minutes, I’m going home.”
And if an older person’s brain has lost oxygen for too long? “If he doesn’t benefit, he doesn’t lose anything,” Dr. John said. “You can make that decision the next day” – meaning, his family can ask to have the life support equipment in the intensive care unit discontinued. Or, he said, “people can make decisions on their own ahead of time by not calling 911.”
But the bottom line for Dr. John, who estimates that he’s resuscitated 300 to 400 people: “I’d give CPR a shot.”
This difference of opinion between two physicians who’ve saved hundreds of lives illustrates how personal these decisions are. For me, they recently became very personal.
My father, who will celebrate his 90th birthday next month, has generally enjoyed good health, taking just one prescription, for diabetes – until July, when he had an apparently mild heart attack. He’s recovered well, thanks, and is back in his independent living apartment playing balloon volleyball and taking tai chi, though he’s now also taking a bunch of added drugs.
Before, he was an almost-90-year-old diabetic, giving him extremely low odds of a successful resuscitation if his heart stopped. Now, he’s an almost-90-year-old diabetic with heart disease, and worse odds. We talked about what to do; he decided that he didn’t want to spend what would probably be his last moments swallowing tubes and having his ribs fractured.
Other people will reach other conclusions. My father, cheerfully and without apparent angst, signed a DNR form last week. It’s taped prominently on his kitchen cabinet, where the paramedics can spot it.
Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”