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Wednesday, September 23, 2015

CPR works, but not as well as most think

Doctors die with grace and dignity.  Actually, anyone who works with sick people for any length of time develops the skills necessary to die with grace and dignity. This is not always true of the general population, especially in a world where people are not exposed to death, and are exposed to the fantasy world of Hollywood where CPR works an amazing 64% of the time.

There are many examples of CPR being performed in a movie or TV show and the person living.  One such incidence that is fresh on my mind occurred in an episode of "Walker, Texas Ranger," which starred Chuck Norris from 1993-2001.  I described it n my post "No Vent, DNR, or Full Code: What's Your Choice?"
What might confuse people is what you see in the movies. There was one episode of "Walker, Texas Ranger," where Chuck Norris's character was having chest compressions performed on him, and his friend who broke his arm was watching on. Then Chuck woke up, the ambulance arrived, and the person who was taken away on the ambulance was not Chuck, but Chuck's friend with the broken arm.
A recent study performed at the University of Southern California Davis School of Gerontology showed that the survival rate for CPR was actually as high as 37%, although the survival rate of CPR performed on TV was a whopping 70%.  No wonder people get a warmed view of what modern medicine can do.

The study also revealed that:
The depictions show CPR mostly being performed on adults age 18 to 65, when in reality more than 60 percent of CPR recipients are older adults over 65... Also, trauma was behind nearly 40 percent of the CPR instances in the shows, even though traumatic injury cases only account for 2 percent of all CPR usage in real life.
When comparing these results to a similar study conducted in 1996, accuracy rates of television CPR depictions appear to not be improving. And though they seem like harmless entertainment, widespread inaccuracies in medical dramas could have real-life consequences.
Harmless indeed! Some experts speculate that the false perception of what medicine can do has lead many to falsely believe doctors can fix any problem, prolong life by "doing everything" including CPR, and that after "doing everything" quality of life will not be impeded.

This is not harmless.  It causes people to delay dealing with end of life care.  It causes people to avoid discussing with their loved ones, with their doctors, how they want to die.  And considering the difficulty of the discussion, doctors tend to avoid the subject altogether.

Just to provide an example, a 67 year old lady with end stage COPD was rushed to the emergency room by ambulance. The first question the doctor asked her was, "What do you want us to do if your heart stops."  She said, "I want everything done."

An hour later she was intubated and put on a ventilator.  Then her blood pressure dropped so low we couldn't feel a pulse.  Now we are forced to begin full blown CPR with chest compressions.  Yes, this did result in ribs cracking.

The chances of her surviving this are not good.  If she does survive, she's going to still have end stage COPD, meaning she is going to feel dyspneic. Only now she is also going to have some pretty bad chest pain due to the chest compressions.

Did we do the right thing.  Well, the emergency room doctor had no choice.  We had no choice but to follow the wishes of the patient, even though we all knew full well that this patient had set a path to a death that was not going to be very pretty.  She was not going to die with grace and dignity.

What can be learned from this.  Doctors must talk to their patients about end of life care.  They must be honest with their patients.  "Hey, you have end stage COPD.  If you should end up in an emergency room in respiratory failure, what do you want done? How far do you want us to take you with our medicine? Do you want CPR?"

Of course this discussion must progress to a definition of what CPR is.  It may progress to a discussion of what intubation is, and of what a ventilator is? It may progress to a discussion about the difficulty of getting a patient with end stage COPD off a ventilator? It may progress to a discussion of recent studies that show that ventilatory support has yet to be shown as useful in patients with chronic respiratory failure?

Options must be discussed. Hospice must be discussed. It must be explained to the patient that choosing to be a DNR, or choosing hospice, does not mean giving up: it means dying with grace and dignity.
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