CPR and Advance Directives: The Facts

CPR performed in the hospital will lead to a patient’s discharge about 18% of the time. In fact, the American Heart Association says that when talking to patients about CPR, healthcare providers should tell patients that roughly 15%, or 1 in 6 patients, may survive to discharge. Certain terminal or chronic health conditions such as cancer or renal failure will reduce the chances of survival even further. If patients do survive, they are at risk for permanent brain damage or some type of impairment in normal functioning.

Hospital health care providers are required to initiate CPR in the event of someone’s heart stopping or if someone stops breathing AND there is no advanced directive stating that CPR is not to be given.

Interestingly, when the public is asked what percentage of people survive after CPR in the hospital and go home, their estimates are closer to 65-75%. That’s a sizable difference.

Why is there such a large discrepancy? It could be we watch the medical TV dramas where a majority of the patients do survive after CPR with normal brain function. I can recall an episode where the patient was speaking in between chest compressions. Speaking! That does not happen. If someone is awake and speaking, CPR is not indicated; nor is it given.

Or could it be that people aren’t told the facts by healthcare providers? Let’s talk about this possibility.

Hospital health care providers are required to initiate CPR in the event of someone’s heart stopping or if someone stops breathing AND there is no advanced directive stating that CPR is not to be given. When a “code blue” is called, an emergency response team hustles to the patient’s room and begins life-saving actions. One doesn’t stop initially to ask about the disease process or why they are in the hospital in the first place or if they have a terminal or chronic illness or what the patient values and believes; they move into the action of saving lives first and asking questions later. While CPR is in progress, the team will eventually discuss the possible causes of the heart stopping or no breathing. It’s too late in the game to talk to the patient or family about percentages of survival.

The patient’s healthcare provider in the hospital may have had conversations about their illness and the recommended tests and treatments that are advised but they might not talk about the possibility of CPR at that time if there aren’t signs that something catastrophic might happen.

When a person is admitted to the hospital, they are asked if they have advanced directives; either a living will or a healthcare power of attorney. If they do, they are asked to bring a copy to the hospital so it can be noted in the chart. It doesn’t matter how many times a person is admitted; the facility asks each time. If they have elected Do Not Resuscitate, it is flagged very noticeably for all of the healthcare providers. If the patient doesn’t have advanced directives, a member of the hospital will provide them with the needed resources. The necessary discussions to complete those forms are often left for the patient to complete at a later date.

The patient’s healthcare provider in the hospital may have had conversations about their illness and the recommended tests and treatments that are advised but they might not talk about the possibility of CPR at that time if there aren’t signs that something catastrophic might happen. And if it does look like something catastrophic might happen, the conversation often goes something like this: “If your heart were to stop or you have trouble breathing and need a breathing tube, would you want us to do CPR or put a tube in your throat?” To which most people are going to say resoundingly “Yes!” Or if the patient can’t answer, the question is asked of the family, who often haven’t had conversations with the patient about CPR, specifically.

I believe we can do a better job of asking these questions of patients and their families. We should start by explaining why CPR was first used; as an immediate response in the community in the event of a sudden cardiac arrest to bide time for life-saving personnel to treat at the scene and then transport to the hospital. And the statistics given by the American Heart Association should be relayed to the patient and family. A discussion is warranted; roughly 15%, or 1 in 6, may survive to discharge and there is a possibility of brain damage or a loss of normal functioning. The cause of cardiac arrest in a hospitalized patient is usually associated with a chronic illness and not a reversible event and is associated with poor outcomes.

This is not an easy subject to talk about. That is why is it so necessary to talk about it.

“Be brave enough to start a conversation that matters.”

– Anonymous