My husband, as well as dozens of others around us several Saturdays ago, witnessed an event drastically different when performed live and in close proximity from how it is portrayed on television – cardiopulmonary resuscitation (CPR). We were enjoying dinner at a restaurant when fire trucks and police cars rapidly approached the parking lot, and when we went outside, we found first responders in the midst of full court press CPR. A vehicle had struck a pedestrian as he attempted to cross the street, resulting in cardiac arrest from the trauma. Cars backed up past the first responders as citizens gazed from behind windows, clearly stunned at what they were seeing.
I remember very well the first time I performed CPR on a patient. Two specific factors that I had not previously anticipated surprised me greatly. First, after only two minutes, I was sweating profusely. The muscles in my shoulders, back, arms, and neck intensely ached, as if I had been running for hours. It is exhausting to perform CPR, and every two minutes we switched off between providers, taking turns on chest compressions in order to bring fresh energy to the situation. The second surprise came when I felt a rib snap under the force of one of my compressions. Think fingernails on a chalkboard times fifty. While that may seem disturbing, medical students and residents are taught to put things into proper perspective – to understand that by the time CPR is necessary, the person is effectively not alive. This is the last hope at restoring life, so fear of injuring the patient should be cast aside in favor of saving the person’s life.
On television, when a patient’s heart stops, everyone speaks in succession in a scripted format, while an indefatigable physician applies gentle chest compressions. Actors and actresses may display tousled hair, but sweating would disturb much-needed makeup, given the lighting. A study published in the New England Journal of Medicine in 1996 found that on three medically-themed television shows popular at that time (ER, Chicago Hope, and Rescue 911), the short term survival rate with CPR following cardiac arrest was an impressive 77% (the most optimistic short term survival rate in the medical literature is around 40%). The patients on television receiving CPR were typically much younger than actual patients with cardiac arrests, and more than the majority of the time, the patients sustained cardiac arrests due to trauma (again, not reflective of reality – primary cardiac causes, such as myocardial infarction or a fatal arrhythmia, are the most common reasons for cardiac arrest).
It is understandable why some patients would not find CPR a particularly desirable option, and in our system of healthcare, they can now indicate the preference for rescuers not to provide CPR when the time arrives. Very elderly patients with multiple medical ailments who experience cardiac arrest while hospitalized have a very low chance of surviving the hospitalization after CPR is performed. Terminally ill patients may express the wish to pass away peacefully. At times, patients state that they just don’t want CPR, and despite not having a defined reason for it, we respect the principle of autonomy in decision-making.
Health care providers routinely ask patients for their preferred code status when admitting them to the hospital. Typically, either a person chooses to be “full code” status, which means “do anything and everything possible to save me if my heart stops beating,” or a person opts to be “do not resuscitate” status, or DNR, which is intended to mean “if my heart stops pumping, do not perform CPR on me.” When I talk to stroke patients and their families about code status, I always emphasize that, in my opinion, DNR means I will still treat their urinary tract infections with antibiotics, and if they require intensive care and nursing, then I will place them in the neurological intensive care unit. DNR means everything except CPR. “Do not intubate,” or DNI, means not to place a patient on a mechanical ventilator to breathe for him or her. Many patients who request the DNR status will also request to be DNI, but not always.
Data demonstrates that this interpretation of the DNR status may not hold true in many hospitals, though. One study evaluated over 8,000 patients with hemorrhagic stroke (intracerebral hemorrhage, or ICH) at 234 different hospitals. It was found that hospitals with the highest rates of giving patients the DNR code status within the first 24 hours of ICH saw a higher risk of patient deaths. Does this mean these hospitals just had sicker patients who were more likely to die? Even after adjusting for age, medical illnesses, and other factors (comparing only sick patients to equally sick patients, leaving a situation where the only factor differing between the patients groups was whether or not patients were of the “full code” status or DNR status), carrying the DNR code status independently increased the chance of death. Hospitals with higher rates of using the DNR code status also saw a lower likelihood of using ventilators, performing brain surgery as a life-saving measure, or performing invasive imaging to identify aneurysms. If DNR only means withholding CPR in the event that the heart stops beating, then why are non-CPR aspects of medical care withheld from patients with hemorrhagic stroke?
Another study found that of patients who underwent elective surgical procedures, again with similar characteristics (age, same types of procedure being performed), patients with the DNR code status were twice as likely to die within 30 days of the surgery compared to those with the “full code” status.
What does this mean? In my opinion, it means that patients and the providers who care for them need to align their expectations. If a patient expects that a DNR status means withholding CPR but otherwise receiving aggressive medical care, and those providing the care think of DNR as meaning not giving every other effort to save a person’s life, then there is a problem. DNR does not mean withholding aggressive medical care. The term for that is “comfort care,” when goals shift from sustaining life and fighting for recovery to comfort becoming the most important goal for the patient over anything else. DNR is not synonymous with “comfort care,” but it appears that it may be morphing into a cousin to it without many patients recognizing this when opting for the DNR status. I am hopeful that, sooner rather than later, there will be a national dialogue about this topic, with patients leading the discussion.