September 9th, 2013
Clear! CPR in the Hospital Is Not Always Good for the Patient
On TV it always seems clear and simple. A patient in the hospital goes into cardiac arrest and the medical team springs into action. After a few tense moments of furious activity, and only after all seems lost, the patient is successfully revived. A few scenes later the smiling and now fully healthy patient thanks the doctor and returns to his or her life as a professional athlete, parent of young children, or criminal mastermind.
Medical professionals know that in real life this is rarely the way it goes. Most patients who undergo cardiopulmonary resuscitation (CPR) are old, frail, and very sick. Many will die and many who survive CPR will die anyway before leaving the hospital. And many survivors will have severe neurological problems.
Now a physician states in JAMA Internal Medicine that hospitals need to change the way they view CPR. When it comes to applying continuous quality improvement processes to CPR, hospitals “tend to focus on the procedural aspects of CPR, such as time to first defibrillation” and the selection of medications, but they “do not regularly scrutinize CPR attempts for appropriate clinical indications.” The author, Jeffrey Berger, is an Associate Professor of Medicine at Stony Brook University School of Medicine and the Director of Clinical Ethics, and the chief of the Section of Hospice and Palliative Medicine at Winthrop University Hospital.
CPR is too often used as a “default action” because of the misconception that there is a “blanket requirement” to use CPR in cases where there is no do-not-resuscitate order, writes Berger. Instead, hospitals should use quality improvement processes to assess when CPR is an appropriate therapeutic option and to avoid CPR when it is inappropriate.
Berger takes issue with the usual, uncritically-held perspective “that cardiopulmonary arrest is itself an indication for attempting CPR” or that CPR is somehow “atypical among medical interventions.”
This perception is evidenced by the use of CPR as a default action rather than within a deliberate treatment plan (e.g., misconstruing presumption of consent in the do-not-resuscitate state law as a blanket requirement to use CPR) and the presentation of CPR as a genuine option even when its therapeutic potential is remote.”