Are you going to have a natural death? Or be subjected to CPR?

When the time comes, very many people want a peaceful death. Even so, there’s always lots more discussion and planning about cardiopulmonary resuscitation (CPR).

Several studies have shown that patients – prudent as they usually are – change their resuscitation preferences depending on what outcome they expect.

But patients and staff have unrealistic expectations about CPR survival. Patients are wildly ambitious. And I was surprised to discover that some staff are unrealistically negative. How can anyone make decisions about resuscitation status, if they have the wrong idea about survival rates after CPR?

So is it ever possible to predict CPR survival rates for an individual?

Stepping right back, there is a fundamental difference between CPR for people who are generally well, but have a cardiac problem: we should be doing MORE CPR for them. Then there’s CPR when someone is in the final stages of a chronic medical condition. For those individuals, their hearts are bound to eventually stop beating as what the Resuscitation Council describes as an “integral part of the natural process of dying”. I think we should be attempting LESS undignified and unsuccessful CPR for them.

To try to help with individual predictions, I carried out a literature review to consider CPR survival rates in terminally and chronically ill patients. I specially focused on high burden clinical conditions. The potential effects of patient age and functional status were also considered. With the increasing focus on home deaths, I concentrated on Out of Hospital Cardiac Arrests.

Some of my results are published in the June 2016 edition of Palliative Medicine: vol. 30 no. 6 Abstract number: PO183

But to summarise – and comment – here:

The first thing I found was how little evidence there is. Although death after chronic illness is something that will affect the vast majority of us, many more researchers concentrate on CPR for the acute-cardiac patients, and how to increase survival for them. Rather than natural deaths.

Part of the problem is methodological. Importantly, more of the sicker patients have Do Not Attempt CPR orders – so they are taken out of the numbers. This artificially increases CPR survival rates for those left in any studies.

Even so, there is a decrease in CPR survival with increasing patient age. This is not linear – there seems to be an especial dip after age 70. All the researchers –  and me too! – are not here saying that some older patients are not successfully resuscitated, just sharing some of the information.

CPR survival rates are especially low for patients with advanced cancer, or advanced liver disease, or with dementia.

Most patients have more than one thing wrong with them. Even so, there is an especial lack of studies for patients with multi-morbidity. Some morbidities are almost ‘positive’ – for example, those who have the cardiac conditions which produce ‘shockable’ rhythms with cardiac arrest have better (if still very low) survival.

Most importantly, the biggest practical – and methodological – problem is that everything keeps on changing. As patients get older and sicker, CPR survival rates decrease. We’re back to the fundamental point that everyone’s heart – including mine, including yours – is going to stop sometime.

I think it would be helpful to be more explicit about this. And to be more explicit that, when a heart stops for someone who has a terminal, chronic disease then often it’s the body’s way of saying that it’s time to die. Although doctors can sometimes make miracles happen then often, even if a heart is restarted beating, patients often die shortly afterwards, in pain (from all the broken ribs)

The other big thing I think we should do is to start collecting different sorts of data. Routine data sources define ‘success’  in terms of getting the heart beating again (return of spontaneous circulation: ROSC); survival to hospital discharge (SHD); or longer term survival. But what about those who had an unsuccessful CPR? Those who died shortly afterwards? And those who chose to have a DNACPR order? We especially need more information about natural deaths.  But we don’t ever collect data about this.

I think we need to start collecting information on good deaths, so that more of us can have them!

 

[I’ve included some links here – there are lots more relevant studies, and if anyone wants to discuss these, please don’t hesitate to contact me!]