Cardiopulmonary resuscitation, or CPR, involves pressing down hard on the chest and forcing air into the lungs to maintain blood flow and is a procedure to revive someone if their heart stops beating and they have died. Unlike most other medical procedures that require our consent to be performed, being resuscitated does not.

Unless healthcare providers and emergency responders are aware of a “Do Not Resuscitate” (DNR) order, they are duty bound to attempt resuscitation. Obviously, in the middle of a medical crisis when minutes are crucial, this is not the time to debate the likely success CPR will have on an individual.  The default is to start CPR.

Television has contributed to an unrealistic expectation that CPR is (mostly) successful and shows patients surviving and returning to their previous level of functioning. One analysis of several medical dramas on television showed that the majority (67%) of their characters survived CPR and were discharged from the hospital, while the true survival number is closer to 20% (International Journal of Emergency Medicine).

Taken together, the mandate to start CPR along with the public’s tendency to over-estimate its success suggests that we need to have information and honest discussions regarding patient preferences about their code status.

Some history

Various techniques have been used throughout history to revive someone who has died, including blacksmith bellows, stretching the tongue, hanging the poor soul upside down or rolling them over a barrel. At times, it was considered blasphemous to try to reverse death as it was seen as “God’s will,” and during the Middle Ages it was outright forbidden. 

As science advanced and the function of the heart and circulatory system were better understood, this eventually led to the development of external cardiac massage or pressure, first performed in Germany in 1891.

Research and breakthroughs continued, but it was not until the 1950s that doctors at Baltimore City Hospital developed the basic steps for our modern CPR that included mouth to mouth rescue breathing. The American Heart Association officially endorsed CPR in 1963 and it quickly became the standard of practice for emergency responders and hospitals.  Ten years later, training was expanded to include the public and improve the chances of surviving a cardiac arrest in the community.

To increase the willingness of bystanders to perform CPR, since 2008 there have been guidelines for Hands-Only CPR that does not involve mouth to mouth rescue breaths.

The initial intent of CPR was to rescue victims of “sudden death” due to drowning, electrocution, surgical complications, or a heart attack in an otherwise healthy person. CPR is most successful in people who are young and healthy and when the cardiac arrest is witnessed. However, it became standard medical practice to perform CPR on any patient suffering a cardiac arrest, regardless of the underlying cause.

What if a person has decided that they do not want to be resuscitated? What if discussions with the medical team support that the burdens of CPR would outweigh the benefits for an individual? This is when an order for Do Not Resuscitate (DNR) could be written based on the best interests or wishes of the patient and/or their health care proxy.

Wishes regarding CPR or code status should be reviewed with each admission to a hospital or health care facility. If surgery is planned, the DNR order may need to be suspended during that time frame. Out in the community, to withhold CPR, a MOLST form (medical orders for life sustaining treatment) should be reviewed, completed and signed by a qualified healthcare provider (physician, nurse practitioner or physician assistant).

Some facts

When discussing survival rates following CPR, a distinction is made between out-of-hospital cardiac arrests and in-hospital cardiac arrests. Each year close to 400,000 individuals suffer a cardiac arrest in the U.S., and the majority occur in the home or workplace rather than the hospital setting. In the community, ideally there is a bystander who witnesses the arrest and is willing and able to administer CPR until emergency medical services (EMS) arrive — all of which can double or triple the chances of survival. The American Heart Association estimates that the survival rate following CPR performed out of the hospital is around 10%. (www.heart.org )

In the hospital setting with trained healthcare professionals and advanced life support equipment estimates vary, but approximately 17% to 20% of patients who are resuscitated survive long enough to be discharged from the hospital.   Survival estimates can be as low as 3% when the patient is advanced in age, has multiple medical conditions, is dependent on others for care or has been a resident of a nursing home. (https://www.the-hospitalist.org/ , Surg. Clinic N. Amer.).

Summary

An otherwise young and healthy individual has the best chance for survival after CPR. Older individuals with advanced medical conditions or nursing home residents, for example, have lower survival rates on average, and performing CPR could cause unneeded suffering. It can be distressing to discuss the code status for oneself or a loved one, but being better informed may help navigate this territory.

Understanding that the default for EMS and healthcare providers is to start CPR when the wishes of the patient are not known makes the conversation important. Also, survival rates are less than most people expect. In one study, nearly half of the patients who initially expressed their desire to be resuscitated, changed their code status when they were informed of the actual chances of survival (Journal of Medical Ethics). Families also struggle to decide if a DNR order is the right choice for their loved one and if the chances of survival are known to be low, this can help to lessen any related guilt or anxiety.

Every situation is unique. These decisions are personal and may be based on faith, culture, and personal values, as well as the “facts.”

Bonnie Evans, RN, MS, GNP-BC, GC-C, lives in Bristol and is a geriatric nurse practitioner, End of Life Doula, and certified grief counselor. She can be reached at bonnie@bonnieevansdoula.com.