Cultivating Wellness by Talking About Choices: Advance Care Planning for Everyone – Post #5

Most of what we think we know about Cardiopulmonary Resuscitation (CPR) we learned on TV, where, by the way, it’s successful over 70% of the time.  Many of us have been trained to perform CPR, but how much do we really know about the outcomes? Here is a great summary from the VA: CPR Outcomes.  CPR is not as successful as most people think.

Googling CPR outcomes can lead to all kinds of confusion.  There are so many factors to consider when sorting through statistics.  Who is the population studied? What was the cause of the cardiac arrest?  How soon was CPR provided? Was it in the hospital or in the community? How was a “successful” outcome defined (survived the episode, survived the hospitalization, survived a year, survived without brain damage, survived but remained of life support)?  Generally I think it is safe to say that at best, an average of 20% of people survive CPR. The Coalition for Compassionate Care of California (CCCC) states that 17-24% of adults who receive CPR in the hospital will still be alive in 30 days, but only 10-13% of adults living independently, 5-10% of adults with serious chronic illness, and 1.7% of adults living in a nursing facility.  No matter what statistics you look at, CPR in real life does not look like CPR on TV.

CPR was designed for a sudden cardiac arrest and can be beneficial when administered in the first few minutes after an arrest.  However, since we can do CPR, and it can be “successful” in some circumstances, it is now an expected intervention to “bring someone back” when they have died, despite the circumstances.  When someone has died as the natural and expected end to a progressive disease process, trying to restart the heart rarely leads to what most people would consider a good outcome, and yet it is the default treatment unless the patient specifies otherwise.

Heart disease remains the leading cause of death in the US, so for a moment, imagine you are an elderly person with Congestive Heart Failure (CHF).  Your slow decline in function is punctuated by increasingly frequent complications which land you in the hospital. Each time, you get tuned up, maybe go to a nursing facility for some rehabilitation for a few weeks, and go back home, but you never quite get back to your baseline.  Whenever you go into the hospital, you are asked something along the lines of, “if something happens, do you want us to do everything?” Well, of course you do…right? Everything they’ve done so far has kept you alive, even when you weren’t sure you were going to make it.

That question is actually code for, “if you are going into respiratory failure (you can’t breathe independently), do you want us to intubate you (put a tube down your throat) and connect you to a ventilator (breathing machine), AND, if you go into cardiac arrest (your heart stops), do you want us to attempt resuscitation (compressions, shocks to your heart)?”  Often, the question is not explained and explored in a way that allows for informed, personal, values-based decision making. So finally you are in the hospital, you “code,” and you receive CPR. Your family is shocked that it has come to this, because every other time, you were able to recover enough to go home. Assuming you survive, you will likely be intubated on a ventilator and have a good chance of having brain damage.  And then…? I knew a doctor once who said about that kind of situation, “I wouldn’t want to have to die twice.” At this point, are you prolonging your life or prolonging your death?

Most people don’t know that their chances of surviving CPR are so low, that “successful” CPR usually leads to life support (at least for a period of time), that they will likely end up with broken ribs and a good chance of brain damage.  So many people have said to me, when making decisions about CPR, “tell them to just pound on my chest a few times to see if it helps, but don’t put that tube down my throat!” I had to tell them that saying yes to CPR is saying yes to any and all life-sustaining treatments that might come along with it, including intubation.  It’s a package deal. Most people don’t know that if paramedics perform CPR in the home and cannot resuscitate a person at least to transport them to the ED, they can pronounce the death but have to leave the body where it is, as it is. Most people don’t know enough about CPR to give informed consent.

CPR has its merits.  If someone in your vicinity has a sudden cardiac arrest, by all means, give them CPR.  It will improve their chance of surviving. My point in going into the gory details is not to scare you or to talk you out of getting CPR if/when your heart and breathing stop.  My goal is to let you know the reality of the situation so you can make informed choices. This is not something that most people need to deal with unless/until they have an advanced illness or very advanced age.  And if you do have an advanced illness or very advanced age, you may very well still choose to have CPR. Some people do want “everything done” to prolong their lives. But some people may not, and those people need to know they have a choice in the matter.

For people with a serious, progressive or terminal illness, or people in their later 80s, I recommend getting educated about life sustaining treatments, including CPR, and considering how those interventions fit with your goals.  Ask your medical team to talk through your options and likely outcomes with you. IF YOU DO NOT WANT AN ATTEMPT AT RESUSCITATION IF YOUR HEART AND BREATHING STOP, YOU WILL NEED A PHYSICIAN’S ORDER TO PROTECT THAT WISH OUTSIDE OF THE HOSPITAL.  If paramedics are called, they will attempt CPR unless they have a doctor’s order telling them not to.

In California, the document we use to show your wishes about CPR and life sustaining treatment is called a Physician Order for Life Sustaining Treatment (POLST).  The home of the POLST is The Coalition for Compassionate Care of California.  The CCCC website is full of information and resources.  For other states, check out The National POLST Paradigm.

Please educate yourself, talk to your family and your medical providers, and plan ahead so that you will get the care and treatment that you want and so that you won’t get interventions that you don’t want.  Don’t wait for your doctor to have this conversation with you.  You can drive your own plan of care.

For more information about advance care planning, please see my previous blog posts on my website.