cpr: duration and outcome jack p freer, md professor of clinical medicine daniel j miori ms, rpa-c...

CPR: CPR: Duration and OutcomeDuration and Outcome

Jack P Freer, MDJack P Freer, MDProfessor of Clinical MedicineProfessor of Clinical Medicine

Daniel J Miori MS, RPA-CDaniel J Miori MS, RPA-CPalliative and EthicsPalliative and Ethics

Millard Fillmore GatesMillard Fillmore Gates

Daniel Sleve, M4Daniel Sleve, M4

CPRCPR

• UniqueUnique—high stakes, life or death, —high stakes, life or death, starkstark

• AbruptAbrupt—must be refused in advance—must be refused in advance

• StandardizedStandardized—routine, ACLS protocol—routine, ACLS protocol

• UniversalUniversal—potential use: —potential use: everyoneeveryone

• IconicIconic—represents promise and misuse —represents promise and misuse of modern technical medical capabilitiesof modern technical medical capabilities

CPR Decision MakingCPR Decision Making

• Presumption to treatPresumption to treat

• No decision=consent to CPRNo decision=consent to CPR

• Documentation regulatedDocumentation regulated

Reasons to Use CPRReasons to Use CPR

• Benefits > BurdensBenefits > Burdens– It’s good to be alive!It’s good to be alive!– Burdens trivial by comparisonBurdens trivial by comparison

• DesperationDesperation

Reasons to Refuse CPRReasons to Refuse CPR(consent to DNR)(consent to DNR)

• Little empirical data in literatureLittle empirical data in literature

• Theoretical constructTheoretical construct– Tomlinson T. Brody H. Tomlinson T. Brody H. Ethics and Communication in Ethics and Communication in

Do-Not-Resuscitate Orders.Do-Not-Resuscitate Orders. NEJMNEJM (1988) 318:43-6(1988) 318:43-6

• NYS DNR LawNYS DNR Law

• SymbolismSymbolism

• Cynical viewCynical view

Reasons to Refuse CPRReasons to Refuse CPRTomlinson & BrodyTomlinson & Brody

• No Medical Benefit—No Medical Benefit—FutileFutile

• Poor Quality of Life after CPRPoor Quality of Life after CPR—CNS —CNS damage, life support etc damage, life support etc

• Poor Quality of Life before CPRPoor Quality of Life before CPR—It’s —It’s NOTNOT good to be alive good to be alive

Reasons to Refuse CPRReasons to Refuse CPR

• Patient is Patient is DyingDying—”Dying” causes —”Dying” causes cardiac arrest (not other way around)cardiac arrest (not other way around)

• Poor Quality of Life after CPRPoor Quality of Life after CPR— — Clinical determination (+ pt/surrogate)Clinical determination (+ pt/surrogate)

• Poor Quality of Life before CPR Poor Quality of Life before CPR — — Patient/surrogate assessmentPatient/surrogate assessment

NYS DNR LawNYS DNR Law

(c) A surrogate may consent to an order (c) A surrogate may consent to an order not to resuscitate on behalf of an not to resuscitate on behalf of an adult patient only if there has been a adult patient only if there has been a determination by an attending physician determination by an attending physician with the concurrence of another with the concurrence of another physician selected by a person physician selected by a person authorized by the hospital to make such authorized by the hospital to make such selection, given after personal selection, given after personal examination of the patient that, to a examination of the patient that, to a reasonable degree of medical certainty:reasonable degree of medical certainty:

NYS DNR LawNYS DNR Law1.1. the patient has a terminal condition; the patient has a terminal condition;

or or

2.2. the patient is permanently unconscious; the patient is permanently unconscious; or or

3.3. resuscitation would be medically resuscitation would be medically futile; or futile; or

4.4. resuscitation would impose an resuscitation would impose an extraordinary burden on the patient in extraordinary burden on the patient in light of the patient's medical light of the patient's medical condition and the expected outcome of condition and the expected outcome of resuscitation for the patient.resuscitation for the patient.

Symbolic Nature of CPRSymbolic Nature of CPR

• Icon of aggressive careIcon of aggressive care—both good —both good and badand bad– Full code = fighting backFull code = fighting back– DNR = giving upDNR = giving up

Symbolic Nature of CPRSymbolic Nature of CPR

• Patient/Family Attitude—Patient/Family Attitude—doubtful that doubtful that patient/family who wish full code really patient/family who wish full code really accept reality of fatal illnessaccept reality of fatal illness

• Physician/Staff Attitude—Physician/Staff Attitude—presence of presence of DNR order implies desire for less DNR order implies desire for less aggressive treatment in other realmsaggressive treatment in other realms

DNR and non-CPR CareDNR and non-CPR Care

• Physician/Staff Attitude—Physician/Staff Attitude—presence of presence of DNR order implies desire for less DNR order implies desire for less aggressive treatment in other realmsaggressive treatment in other realms

• Beach MC, Morrison SRBeach MC, Morrison SR, The Effect of Do-Not-, The Effect of Do-Not-Resuscitate Orders on Physician Decision-Making. Resuscitate Orders on Physician Decision-Making. J J Am Geriatr SocAm Geriatr Soc (2002) 50:2057–2061,. (2002) 50:2057–2061,.

DNR and non-CPR CareDNR and non-CPR CareBeach and MorrisonBeach and Morrison

• Physician surveyPhysician survey

• 3 Clinical vignettes3 Clinical vignettes

• 2 Versions of each2 Versions of each– One with DNROne with DNR– Other no DNROther no DNR

• Sequential treatment decisionsSequential treatment decisions

DNR and non-CPR CareDNR and non-CPR CareBeach and MorrisonBeach and Morrison

Reasons to Refuse CPRReasons to Refuse CPR

CynicalCynical

• Because the physician approaching the Because the physician approaching the patient/family thinks it’s a good idea and patient/family thinks it’s a good idea and persuades the decision maker persuades the decision maker

• Gory details (“break your ribs”)Gory details (“break your ribs”)

• Often no mention of survival/outcome Often no mention of survival/outcome datadata

Rational ApproachRational ApproachChoudhry NK, Choudhry S, Singer PA.Choudhry NK, Choudhry S, Singer PA. CPR for CPR for Patients Labeled DNR: The Role of the Limited Patients Labeled DNR: The Role of the Limited Aggressive Therapy Order.Aggressive Therapy Order. Ann Intern Med Ann Intern Med (2003) (2003) 138:65-68.138:65-68.

• Presumes people make DNR decisions based on Presumes people make DNR decisions based on probability of poor outcome with CPR.probability of poor outcome with CPR.

• Overlooks high-yield circumstances (relatively good Overlooks high-yield circumstances (relatively good outcomes with CPR):outcomes with CPR):– Witnessed “shockable” rhythmsWitnessed “shockable” rhythms– CPR in ORCPR in OR– Iatrogenic/proceduresIatrogenic/procedures

Rational ApproachRational Approach• Witnessed “shockable” rhythmsWitnessed “shockable” rhythms• CPR in ORCPR in OR• Iatrogenic/proceduresIatrogenic/procedures

Choudhry: Choudhry: • LATO order: Limited aggressive therapy; LATO order: Limited aggressive therapy; • Intermediate status. Intermediate status. • UnwieldyUnwieldy

Short Code.Short Code.

Code Duration and OutcomeCode Duration and Outcome• Variety of outcome measuresVariety of outcome measures

– Restoration of spontaneous circulationRestoration of spontaneous circulation– Survival at 24 hoursSurvival at 24 hours– Survival to dischargeSurvival to discharge

• Variety of timeframesVariety of timeframes– < or > 5, 10, 15, 20 min< or > 5, 10, 15, 20 min– Ranges (5-10, 11-15, 16-20 etc)Ranges (5-10, 11-15, 16-20 etc)– Mean CPR time among survivalMean CPR time among survival

Short CodeShort Code

• Allows patient to avoid outcomes of prolonged codeAllows patient to avoid outcomes of prolonged code• Eliminates generalizing DNR to other decisionsEliminates generalizing DNR to other decisions• NOT a sham code ( “slow code,” “show code”)NOT a sham code ( “slow code,” “show code”)• NOT a partial code (“CPR but DNI”)NOT a partial code (“CPR but DNI”)• Go all out—but for less timeGo all out—but for less time• No confusion in initiating codeNo confusion in initiating code• No confusion in running of codeNo confusion in running of code• No confusion in ending codeNo confusion in ending code

Cooper & Cade 1997

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CPR survival rates related to the arrest duration (min)

Millard Gates 12/06 – 12/07

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CPR survival rates related to the arrest duration (min)

Survived Procedure

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Cardiac Resuscitation Survived Resuscitation

Survived 24 Hours

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Cardiac Resuscitation Survival at 24 Hours

Survived to Discharge

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0 to 5 6 to 10 11 to 15 16 to 20 21 to 25 26 to 30 31 to 35 36 to 40 41 to 45 Outliers

Cardiac Resuscitation Survival to Discharge