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ethics and advisory

Making Decisions About CPR

Historically CPR was intended to be used in situations where death was accidental, such as drowning or electrical shock, or when an otherwise healthy person experienced a heart attack. Thousands of lives are saved each year with CPR during such isolated events. However, attempting CPR is not always the right choice and may represent a violation of a person’s right to die with dignity. Today, in both hospitals and nursing homes, attempting CPR has become a standard procedure and is offered to everyone.

Cardiopulmonary Resuscitation (CPR) is the combination of measures performed to attempt to get oxygen into your body and maintain blood circulation to the brain and heart in the event that breathing stops and/or the heart stops beating. This is also known as cardiac arrest. There is no guarantee of success with attempted CPR.

These measures* may include:

  • A=Airway and B=breathing: Mouth-to-mouth resuscitation initially, then this may require bag and mask or a breathing tube. A tube may be put through the patient’s nose or mouth into the lungs in order to force air into and out of them. A ventilator or respirator (breathing machine) may be required as the next step.
  • C=Circulation: Chest compressions where the chest is forcefully pressed in order to pump blood from the heart into the rest of the body. Electric shock (defibrillation/cardioversion) may be used in an attempt to restore normal heart rhythm. Medications are injected in an attempt to restore normal heart rhythm and blood pressure.

*Any or all of these measures may be used in the sequence/steps of resuscitation.

The decision to attempt and use CPR is not a simple one. There are certain situations when CPR should not be used or attempted. The person’s health condition, chances of survival and quality of life need to be considered. It is okay to choose not to attempt CPR. It does not impact any other treatment choice.

How Effective is CPR?

  • The effectiveness of CPR depends on previous health, the cause of cardiac arrest and how soon CPR is performed after the heart or breathing stops.
  • The survival rate for CPR decreases when there are multiple illnesses present.
  • CPR will not cure an underlying disease but may restore heartbeat and breathing.
  • CPR is not likely to be beneficial if advanced life-threatening illnesses are present.
  • Cardiac arrest is usually the final step in the body’s natural process of aging leading to death.

CPR Survival Rates

The evidence overwhelmingly shows that CPR is not able to restore most people who are at the end of a life-threatening illness to their previous level of functioning. CPR is of no medical benefit to these patients. On television, CPR is not shown quite accurately—in real life, the process is more brutal with lower success rates. When a person is in failing health from a serious or progressive illness, CPR has little chance of success. Results may be only partially successful and temporary.

CPR for hospitalized patients is associated with poor outcomes, as the cause of arrest is usually associated with advanced chronic illness rather than an easily reversible heart or breathing failure.

The largest and most comprehensive source of in-hospital CPR outcomes data is the National Registry of Cardiopulmonary Resuscitation, reporting 14,720 resuscitation attempts (2000-2002) in adults from 207 U.S. hospitals. Survival 20 minutes after CPR was 44%, but only 17% of all CPR patients survived to discharge.

Fewer than 15% of patients who have CPR while in the hospital’s intensive care units survive and are able to function as they used to. Studies report that CPR is successful in only 5-12% of patients whose heart or lungs stop working outside the hospital and who receive CPR before entering the hospital. Only 1-5% of long-term care patients receiving CPR survive CPR because such patients usually have health problems affecting many organs in the body.

It is normal and instinctive to try to save life, no matter what the cost or outcome. Some people are concerned that not doing everything possible to preserve life is the same as “killing” someone. It also simply means respecting the end stage of a disease and allowing the natural course of events as the physical body naturally shuts down.

Risks of CPR

Chest compressions during CPR can cause bruising/pain on the chest, broken ribs or a collapsed lung.

If CPR is successful, care may need to be provided in an intensive care unit. A breathing machine may be necessary.

Even if breathing and heart beat is restored by CPR, brain damage may have occurred. CPR may delay or prolong the dying process.

Who Will Decide About CPR?

You and your physician will decide whether CPR should be attempted during a cardiopulmonary arrest. If you are in the hospital, you will be asked about your choices and personal preference on admission and if there are substantial changes in your health status. It is important that family members are clear on your decisions regarding CPR.

What if I Decide I Don't Want CPR?

Whether the decision is to choose or reject CPR, appropriate medical and spiritual care will continue to be given. Comfort is always provided, not allowing an individual to suffer or struggle. Just as there are numerous treatment options to attempt to fix and cure, there are measures to keep people comfortable and allow dignity without hastening death. At Altru, you will be asked to sign a document confirming your request called a POLST (Physician’s Orders for Life Sustaining Treatment). You have the right to change your mind at any time.

What if I Can't Express My Wishes?

If you are unable to communicate or make decisions for yourself, your healthcare provider should make treatment decisions based on your wishes, if these are known. If your wishes are not known by your healthcare provider they will take in account your known values, information received from those who know your beliefs, and aspects of your culture and religion that would influence medical decisions.

Can I Put My Decisions in Writing?

Yes. Using Advanced Healthcare Directives is the best method to prepare written instructions about the type of care you would want if you were to lose your decision-making capacity or be unable to make your wishes known. CPR is one of the major treatments addressed in this type of document. It also relieves your loved ones from having to make this hard decision. Individual medical problems and overall health, life goals and beliefs about life support are all important considerations in determining whether CPR is the right choice. This may change over time as well. Discuss your wishes and concerns about CPR with your family and your physician or healthcare provider. Should you need more information or want to discuss your wishes about CPR, you are encouraged to contact your physician, healthcare or spiritual adviser.

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