Let’s Talk About Cardiopulmonary Resuscitation (CPR)
By Judith Schwarz, PhD, MSN
NPR published a wonderful article in May about CPR written by Dr. Clay Dalton. He began his article by describing an RN’s refusal to do CPR on an elderly woman who experienced a cardiac arrest in a senior living facility. This woman’s family stated she had repeatedly told them she wanted to die “naturally” without any life-prolonging interventions. The article did not mention whether her physician was aware of those wishes, or whether a “do not resuscitate” order or a MOLST form (medical orders for life sustaining treatment) had been completed for her.
There is a great deal of misunderstanding and incorrect assumptions about the effectiveness of CPR. The article notes that use of CPR was initially thought to be miraculous — easily provided and it saved lives. Certainly, the success rate of CPR on television shows was/is reassuringly high (70%), which encourages the belief that everyone should know how to do CPR. In the 1970s, CPR classes for the public became widely available in schools and community centers and other settings. Learning how to do CPR seemed almost a civic duty.
There was no discussion during these trainings about how successful such responses were, nor was success following CPR defined. Indeed, one report that analyzed the results of many studies found that the survival rate of “bystander-initiated” CPR was only about 10%. CPR administered within a hospital has slightly better odds, but still only 17% survive. The likelihood of survival also decreases significantly with age.
Of the individuals who survive, many are physically harmed by CPR and subsequently experience a diminished quality of life. The physical harm of CPR frequently includes broken or cracked ribs and sometimes fractures to the sternum (breast bone), liver cuts/tears, and bleeding in the lungs. Due to this associated trauma, more than half of those who received CPR and survived report that they wish they hadn’t received it even though they lived. They cannot return to their “before” selves, and two studies found that only 20–40% of older patients who survive CPR are able to function independently.
However, the direct physical harm of CPR is frequently not the worst of their trauma. Their diminished quality of life is often caused by brain injury that occurs while the body is deprived of oxygen in the minutes before CPR begins. Thirty percent of survivors of in-hospital cardiac arrest who receive CPR will experience significant neurological disability. It is also not just patients who suffer — clinicians also suffer. In one study, 60% of medical providers experienced moral distress following their participation in “futile” resuscitations. Moral distress frequently leads to burnout and loss of interest in their caring profession.
Surely there are individuals alive today because of CPR who are grateful to have had this intervention. But unfortunately, this is not the reality for many. So, what can we do about these issues with CPR? Dr. Dalton calls for better communication between clinicians and patients, and better education of members of the public. He notes that more than half of patients changed their mind about wanting CPR after learning the true survival statistics or after watching a CPR video. Although most Americans believe it is important to discuss their end of life treatment preferences with their providers, a mere 32% have done so. Similarly, discussions with family members or appointed health care agents tend to use clinically vague langue like “no heroics.” Clinicians cannot interpret or follow such vague directions.
The NPR article concluded with advising that clinicians begin these talks early, before a medical crisis. Dr. Dalton also recommended that clinicians refrain from asking patients, “Do you want everything done?” Instead, education and conversations are needed about each option. Also, if CPR would likely be futile, it should not be recommended as an intervention, and instead physicians should recommend “allowing a natural death” (instead of CPR).
Please consider your wishes, and speak with your medical provider if you have questions about what you can expect if you receive CPR. If you do not wish to be resuscitated, New York has a specific “do not resuscitate” (DNR) form your medical provider can complete to document your wishes as an official medical order. If you have a serious illness, then ask your doctor about completing a MOLST (medical orders for life sustaining treatment). These forms are important — if an ambulance is called, the EMTs will likely try to resuscitate you if you do not have a medical order.
Unfortunately, TV shows and movies continue to misinform the public about CPR. More education is needed to raise awareness of the realities of CPR and to ensure that patients are receiving interventions that truly reflect their values. Please help us raise awareness, and let your loved ones and your medical team know your wishes regarding CPR.
Judith Schwarz is a PhD prepared nurse, and has provided End of Life Counseling for 20 years for adults with living incurable/progressive or terminal illnesses. As the Clinical Director of End of Life Choices New York (EOLCNY), she answers New Yorkers’ questions about a range of end of life issues.
To learn more about EOLCNY’s support program, click here. To connect with Judy, please email judith@eolcny.org.
