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.”


2 Responses to “Clear! CPR in the Hospital Is Not Always Good for the Patient”

  1. William DeMedio, MD says:

    There is a thing called a POLST (physician’s orders for life sustaining treatment) form. One of these should probably be present in every chart.The form enables the patient to select which life saving measures they desire. A person who refuses CPR should not get CPR. Unfortunately, the “default” action to resuscitate may not necessarily result in a good outcome, and in fact on the hospital floor this is often the case. Some people who receive CPR on the hospital floor are not successfully resuscitated or suffer complications “worse than” death.

    In the units, the most frequent cause of a cardiopulmonary arrest is a malignant arrhythmia, hypovolemia,or respiratory depression, which are often remedied with some fluids, medications, electricity, or oxygen delivery. Since people there are continuously monitored at carefully it is often obvious what the cause of the arrest was and the ICU nurse is already on it as a code is called. The cardiac care unit was created so the nurses and physicians could quickly defibrillate, or otherwise treat a malignant arrhythmia. Cardiac care units greatly improved the in hospital survival of myocardial infarction. If a code called in the ICU hasn’t been corrected by the time the house physician arrives it often is because initial appropriate treatment of the problem did not work and something not as easily remedied is going on.

    If every patient has a POLST form done on admission, many unnecessary uses of CPR could be avoided. Each person deserves the dignity of deciding what should be done with them in the case their heart or lungs stop working. A good “quality indicator” of a health care facility should include what the fraction of patients who have a POLST form is.

    Time to defibrillation in the intensive care unit or the telemetry unit should be no more than 30-60 seconds. This is usually the case due to direct monitoring of the ekg. Unfortunately the time to defibrillation on the hospital floor can be much longer than several minutes because there is no continuous monitoring of the ekg. Wireless technology, information technology, and leads which could be “stuck on every willing chest” already exist which would quickly identify a malignant arrhythmia on the floor and automatically notify personnel that a patient is in ventricular fibrillation, who can then more quickly defibrillate. The monitoring could all be done by machine and at little cost compared to the actual cost of an American hospital stay. Unfortunately the “medico-legal” climate would suggest to patients and lawyers that anyone wearing such leads would be occupying a “monitored bed” and the same “standard of care” would apply.
    I would suggest that QI systems look at the rate of POLST form generation as a quality indicator. The outcome of every CPR episode including appropriateness and complications,should also be looked at. A short post code debriefing should occur. In cases where there is no POLST form or the code status is in doubt, the default action should still be to perform CPR, because in retrospect if CPR is not performed and the patient dies, the family may hold the personnel or facility accountable for an act of omission.

  2. Enrique Guadiana, Cardiology says:

    One more time this is a case in which the expectation and misconceptions of the people play an important role. Many patients and their families doesn’t want to give authorization to DNR because they are afraid the medical staff will not perform in the same way and let them die. Also If you do not talk with your patient about DNR and their family, was not expecting or prepare for the patient death and you don’t perform CPR the possibilities for a lawsuit increase dramatically. So talk with your patient and educate them especially “their families” about this very important and sensitive issue and it’s very important to respect the patient wishes even if you don’t agree.