Yesterday at The Washington Post, I wrote about a controversy in which a 911 caller who identified herself as a nurse refused to give CPR to an 87-year-old woman who’d collapsed at a Bakersfield, California independent living facility. (Unlike a nursing home, the facility did not employ medical staff, and, according to the Associated Press, the caller worked there as an administrator, not a medical provider.)
In the tape, which you can listen to below, the 911 dispatcher urges the caller to begin CPR. When the caller explains that the facility’s policy is to leave medical care to the emergency responders, the dispatcher grows increasingly frustrated.
Dispatcher: she’s going to die if we don’t get this started. do you understand?
Caller: I understand.
Later….
Dispatcher: I understand if your boss is telling you you can’t do it…But … as a human being … you know … is there anybody that’s willing to help this lady and not let her die?
Caller: Not at this time.
*
Indeed, the woman does die. And the internet and tv talk shows had a field day.
“It’s certainly shocking when you hear a nurse say she can’t perform CPR on a patient who clearly needs it,” said Dr. Roshini Raj on the Today show. “CPR absolutely saves lives. It doesn’t have the success rate you might think if you watch on TV, but it could potentially [save the victim’s life] in this situation,” Raj tells viewers.
She’s right about TV creating unrealistic expectations. As I write in my Post piece,
A 1996 New England Journal of Medicine study found that television CPR had a success rate of 75 percent — far greater than even the most ideal real-life situations.
Even in the very best case scenarios, only about half of victims survive to be discharged from the hospital — and that’s when CPR is enhanced with advanced technology (AEDs) and highly trained personnel at the ready. Most importantly, those success rates happen only when CPR is given to the victims the technique was intended for — people experiencing sudden cardiac arrest.
CPR was developed for scenarios where the victim is stricken with something that momentarily stops the heart — lightning, a drowning, a minor heart attack or sudden cardiac arrest. Restart the victim’s heart, and life resumes. The technique was never designed to prevent age or disease-related deaths, says David Newman, director of clinical research in the department of medicine at Mount Sinai School of Medicine in New York City.
“It’s crazy talk to believe that everybody should always get this invasive, punishing burdensome procedure when we know that the overwhelming majority — even the people who might be considered the most appropriate — are not going to survive it,” Newman says. “Chronically debilitated nursing home patients are not the patient population that CPR was developed for.”
George Lundberg, a former editor of the Journal of the American Medical Association who is now editor at large for MedPage Today, is even more blunt. People die for many reasons, he says, but usually when the heart stops, it’s because the person has a disease that has reached the end of its course or a severe, unsurvivable trauma that can’t be fixed by beating on their heart. “The idea that just because someone’s heart stops you should start it again is ridiculous, but it’s been ingrained in our society and it’s hard to stop,” Lundberg says.
Yes, CPR saves lives, but the cold, hard truth is that most people can’t be saved by CPR. In a MedPage Today editorial published last year, Lundberg wrote,
If an average adult keels over in the street, is found unresponsive and pulseless by a bystander, and is administered CPR while a 911 call is made, the odds that such a person will emerge from the eventualities of the resuscitation effort healthy and with a normally functioning brain are about 2 percent.
The odds are even more dismal for trauma victims. If a person’s heart has stopped because of traumatic injuries, “There is no amount of CPR that can reverse the condition that led to the cardiac arrest,” Newman says.
Nor is CPR a cure for people with progressive disease. “We’ve gotten sidetracked from the original intent when we start pushing for patients in longterm care settings to receive CPR,” Newman says. “In those cases, it’s rarely a very sudden and unpredicated cardiac event — it’s much more likely to be the culmination of a longstanding illness.”
Lundberg told me that most of the physicians who responded to his MedPage Today editorial said that they never want CPR performed on them, and that seems like a telling detail. In the movies and on TV, it just takes a few pushes on the chest and, voilà! The victims cough a few times and they’re back to their old selves. Doctors understand that this is rarely the case. When CPR “works,” a more likely scenario is that the person ends up in the hospital receiving even more interventions and suffering from some kind of brain damage, Lundberg says.
In light of all this, it’s possible to view the Bakersfield caller’s decision as caring, instead of heartless. I’m certain that if it were me, I wouldn’t want my last moments of life filled with someone bashing my chest. But that’s a personal decision. Which is why everyone should have an advanced directive specifying their wishes.
It’s not clear whether the Bakersfield woman had put her wishes in writing. Her family told the Associated Press that their loved one understood the limits of the facility and is at peace.
Still, I understand the dispatcher’s impulse to do something — anything.
Which leads me to wonder if the most important benefit of CPR is that it gives bystanders something tangible to do. I know several people who’ve given CPR to accident victims who didn’t survive, and they told me that they have no regrets. They did everything they could, and that offered some measure of comfort.
There’s no downplaying the agony of watching someone die. I’ve done it, and I would never wish that experience on anyone. What I learned from this unbearably helpless experience is that our culture does not prepare us to let go.
*
Image: Shutterstock.com
You may be interested by a recent paper in New England Journal of Medicine, showing that CPR helps… the family to better cope with bereavement, and reduces the post-traumatic symptoms of losing a beloved one.
http://www.nlm.nih.gov/medlineplus/news/fullstory_134908.html
I think you’re missing a few big things here. The biggest is the distinction between CPR and defibrillation. CPR is designed to keep blood flowing until the heart returns to a consistent pumping rate. That return is more likely to occur in certain cases after a defibrillator’s electric shock.
Well equipped nursing homes shouldn’t be relying on CPR. They should have AED’s and possibly full defibrillators. They obviously work in many cases, but the question to use them rests with the patient’s previous requests and the evaluations of the medical staff.
Instead of focusing on the ineffectiveness of just CPR, you could have written a bit more of the benefits getting a brief training on AED usage and AED and knowing where they are in the public buildings one frequents. AEDs are specifically designed to be used by people without significant medical expertise. Having more accessible AEDs and more people trained to use them. might not improve survival to 50%, but it will improve it much more than 2%.
I also think your comment on trauma is misleading. CPR doesn’t work with trauma, but a good samaritan or possibly even a professional, might not be able to tell whether the heart stopped due to trauma. Someone gets in a car accident, is bleeding from their head, walks out of the car, and collapses. Did they collapse from severe internal bleeding (CPR might not be useful) or did they just have superficial wounds and collapse from a “standard” heart attack after a stressful event?
bsci: good point about the difficulty sorting out trauma from heart trouble. For instance, if someone crashes their car, there’s a small chance that a heart attack or sudden cardiac arrest caused the accident. It’s someone’s life at stake, so even if the odds are low, it’s worth trying.
Please have a look at the Washington Post piece, which gets into much more detail about CPR and when/how to do it.
I quote an ethicist: “When in doubt, you try.”
@Christie I don’t see a Dr in your title, you’re truly not qualified to write this article. If my heart stops i pray to god that someone gives me CPR.
Wow. I hadn’t planned on commenting, but people seriously think this way?
#1: Since there’s only a remote chance you might save them, why try?
#2: Since they’ll probably only live for a short time after you’ve revived them, plus their life wasn’t so good to begin with and CPR might have hurt them further, don’t do it.
There’s scientific thinking for you. If I misunderstood, I apologize. If not, then I will remain flabbergasted.
From my CPR instructor, “if you are doing it properly, you will flail the recipient’s chest.” Not a pleasant thing to contemplate if you’re in your 80s or 90s…
Interesting topic. The comments thus far seem to back up your statements.
I had the opportunity to try and save someone who was in a car wreck years ago. And, while I couldn’t do much to free them and start CPR, I’ve always wondered if I could have done more. The reality is, that I couldn’t, as paramedics arrived on scene before I had any real opportunity to do anything, but it doesn’t stop my wondering.
Death is a scary and emotional topic that none of us are really prepared to deal with, both ours and others’. So, how does anybody make the determination of whether to try and save anothers life? I think this is a question that has to be answered individually. And, while I would hope most would choose to try, I know many who are afraid to get involved.
No doubt about it most times CPR is a measure so you don’t feel hopeless. As a Paramedic I had to decide whether to continue rescus on a 6 year old child who had been in arrest for over 30 minutes with several live breathing patients in need of transport and my next ambulance was over an hour away. I waited for days second guessing myself on my choice before the autopsy results came back as injuries not survivable. We have a belief that even if the person has been down for days that CPR is indicated. To paraphrase the ACLS Manual “for a lot of hearts that last beat was a good thing” The cold hard facts are that we do CPR because someone has died, and if everything goes well maybe they will live again. A teenager with a sudden dysrhythmia, I would bust my hump for. A 106 year old NIDDM quadruple amputee probably not.
Mr. Shots, if your heart stops, I’m sure someone will try CPR on you if you are in the right place at the right time. Hopefully they will have an AED machine nearby to increase your chances of survival. But I think you missed the point of this piece: Christie Aschwanden is a science journalist who has reported a story with different points of view, pulling from the scientific literature and the experience of people in the field. A doctor would have written an article according to their own viewpoint, on one side or the other. People can be right without “Dr.” as a title, and doctors can be wrong with it.
I recently completed a government first aid course here in France. Unlike other first aid courses I had taken in Canada and the UK, they were very clear that the goal was not to restart the heart and/or breathing but to keep oxygenated blood getting to the brain until the emergency response people arrive. They even said that there is essentially no chance that you will restart the heart, but that there is a chance that you can minimize the almost certain brain damage.
CPR is most successful when there is a witnessed arrest and CPR is used to keep the brain oxygenated until an AED can be applied. Under these circumstances the save rate is around 10-15%, with better results when the victim has arrested due to electrocution, fresh water drowning, and other non-cardiac, non-trauma events (i.e. the heart and major organs are not damaged.)
As an EMT, my wife has had a number of CPR saves (and many, many more that were not saved.)
With a witnessed arrest, immediate CPR as a bridge to an AED within 5-10 min., the chances of brain damage due to oxygen deprivation are minimal, assuming the AED can restart normal rhythm.
While the odds are not great, there’s plenty of people walking around living normal lives who are eternally grateful that CPR was administered.
In the heat of the moment, as a layperson, it is very difficult to make an accurate judgement within seconds as to whether CPR might be appropriate. Personally, I would err on the side of sustaining life, as I don’t feel I’m qualified to think through all the complexities presented in Aschwanden’s article during the brief window of opportunity that CPR presents.
An anecdote about doctors and CPR: I was at a party with at least a dozen doctors of various specialties when an elderly (late 70’s) man arrested on the dance floor. Not a single doctor would approach the victim, but the sole volunteer EMT in the room began CPR; first responders arrived within minutes and applied an AED. The victim was wheeled out to the ambulance alert and lucid, and lived for another 7 years. Certainly an unusual case, but nonetheless demonstrates just how difficult the snap judgement not to start CPR can be.
Tone: that’s a fascinating anecdote. Thanks for sharing.
Of course, it’s the success stories that people remember and talk about, but the stakes are high here and one life saved is one life saved. Can’t discount that…
Yes, CPR works. As a EMT-B I can say this with confidence. We do have patients who walk out the ER and go back to normal life, though it is rare. No doubt with some conditions CPR is worthless, but until the paramedics wire up the patient and get a heart rhythm, this is an unknown.
Starting CPR immediately raises the survivability rate exponentially by manually moving oxygenated blood to the brain until ALS (advanced life support) arrives. Statistics by the King County, WA EMS service clearly shows that delays, interruptions and inefficient CPR dramatically lowers the patients chances.
(Everyone should know and start CPR immediately. 100 compressions a minute, piston like, allowing a full rebound of the chest. Don’t worry about giving breaths and keep up the CPR until the ambulance crew instructs you to hand over to them. You may indeed save someone’s life.)
This is just sad:
Dispatcher: I understand if your boss is telling you you can’t do it…But … as a human being … you know … is there anybody that’s willing to help this lady and not let her die?
Caller: Not at this time.
As Vito describes, CPR is not about restarting the heart. It is simply an interim method of keeping the brain oxygenated until Advanced Life Support (or at a minimum someone with an AED) arrives and attempts to restore heart function. CPR is the best known method for someone with limited training to prevent brain damage during the initial cardiac event.
Recovery is strongly correlated to: the extent of heart damage, the timeliness of ALS, and the prompt application of CPR. The layperson who witnesses a cardiac arrest has zero ability to assess the first two (heart damage, and ALS arrival time), but has complete control over the third (CPR.)
The arguments made against CPR could have hypothetically been discussed with Oskar Schindler – “the odds of your saving 1,200 Jews are really quite slim, they’re more likely to suffer an even more gruesome death if you intervene and fail, and 1,200 is really such a tiny percentage of 6,000,000 that it hardly matters.”
One thing that the article doesn’t address is the ability of CPR to keep the organs and tissues more viable for the potential that the patient may be (or become, through the decision of surviving relatives) an organ donor.
As well as that, a successful resuscitation of a terminally ill or injured patient can offer surviving family members a little more time to get to the patient’s bedside and say their last goodbyes.
But aside from all that, outside the clinical setting, what does a terminally ill patient look like?
The medical component of the article is dated. One of my sons had chest pain 2 years ago, was transported by EMS to the closest ER at which point he developed a “really ugly” atrial fibrillation. It took in excess of 40 minutes of medications during closed chest CPR by tag-teaming EMS crew, nurses and technicians to get a “restart”. A 40-minute period of even professional multi-team CPR with oxygen traditionally produced massive brain damage if the patient even survived. The ER physician stayed in the game well past common sense since the hospital had taken delivery of hypothermia inducing equipment. The brain damage resulting from anoxic insult (low oxygen levels in the brain) occurs over the hours and days AFTER the anoxic event. This is due to swelling and inflammation within the brain. Those swelling and inflammatory processes are blocked by cooling the body core. With the family’s consent, my son was paralyzed (to prevent shivering), put on a respirator, and cooled to 90 degrees F during the next several days. After over a year, if there is a brain deficit, I cannot detect it.
Therefore, it seems reasonable for any person present who knows CPR to “go for it”. If the patient survives until EMS arrives, start talking hypothermia to the EMS crew. If possible also inform the patient’s family about possible hypothermia therapy. (Hypothermia therapy may not be required if the anoxic episode was “brief”.) In the case of a “longer” anoxic episode, if the hospital does not have the hypothermia equipment, the family should be considering patient transport or hypothermia equipment transfer to the hospital IMMEDIATELY.
Surviving cardiac arrest is admittedly a crapshoot. If bystanders do CPR promptly and call 911; if the EMS crew is well trained and on-site quickly; if the hospital staff is competent and well equipped, there is now a pretty good chance of survival with minimal or no brain damage. If CPR is not done, the chances of survival with an intact brain are markedly reduced.
Unless I know for certain that the patient is already at death’s door due to a terminal illness and resigned to death or there is obvious massive trauma involved, I don’t see any alternative but to “go for it”. The field CPR might give the “pros” a chance to save the patient’s brain. I you want a guarantee, go buy a new wide screen television set.