A recent New York Times “Well” column, titled “The CPR We Don’t See on T.V.,” revealed an eye-witness view of in-hospital cardiopulmonary resuscitation (CPR) – a far cry from the television show depictions of the activity. Vermont Medicine (VM) asked University of Vermont Associate Professor of Medicine Renee Stapleton, M.D., Ph.D., a pulmonary and critical care specialist at Fletcher Allen Health Care, about the realities of administering CPR in the critically ill or chronic disease patient population – an area about which she and several colleagues, including Prema Menon, M.D., an assistant professor of medicine and current Ph.D. candidate in the Center for Clinical and Translational Science, have studied and published a number of papers. An abstract of her most recent paper, published online in June in the journal Chest, can be viewed here.
VM: Based on your research, can you comment on which populations have the least to gain from in-hospital CPR – for example, those who may experience negative outcomes due to CPR?
Stapleton: We know – from the research we have done using data from all Medicare inpatient admissions in the U.S. from 1992 through 2005 – that surviving after in-hospital CPR to hospital discharge happens about 18 percent of the time. That’s less than one in five patients. And we have identified some particular subgroups of patients who survive less often. These include patients with chronic obstructive pulmonary disease (COPD), cancer malignancy, cirrhosis of the liver, kidney disease, diabetes, and advanced congestive heart failure. Also, critically ill patients receiving mechanical ventilation have lower survival after CPR, as well as patients who have already receiving in-hospital CPR once during the same hospital admission.
Other outcomes besides surviving to hospital discharge are also generally worse in patients with the above chronic diseases or who are critically ill. If they do survive to hospital discharge, these patients are less likely to be discharge to home, experience more hospital readmissions, and have much shorter long-term survival. For example, patients with advanced cirrhosis have a median long-term survival of 2.8 months after CPR compared with 26.7 months in patients who have no chronic disease.
VM: How has your research informed how you advise critically ill and chronically ill patients regarding resuscitation orders?
Stapleton: I like to be very open and communicative with my patients and their families. Talking about CPR and other preferences for end-of-life care takes a lot of time, and it definitely makes a difference to our patients if we take the time to give them all the information they need. I start by learning about their values and their goals of care. One patient who is chronically ill might feel that living in a nursing home would be acceptable, while another patient may never tolerate that. Decision-making with patients and families is a shared process, and it’s very important to find out about patient’s wishes. I then explain what it means to receive CPR, what is likely to happen during and as a result of CPR, and about how media portrayal of CPR is deceiving. With an understanding of the patient’s values and goals of care, as well as knowledge of their medical condition and the information we have learned through research, I often then make a recommendation based upon my experience and explain why I might make that particular suggestion. Patients and families may or may not agree with that recommendation, which is o.k., and sometimes discussions continue for many visits. As a physician, it’s my job to work together with patients and their families to help them make the most informed decision possible.
More information: Stapleton participated in a special UVMFletcher Allen Community Medical School panel presentation on “Patient Choices: Navigating End of Life” in September 2013. Find links to the session’s PowerPoint slides and video here.