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ORIGINAL ARTICLE

Cardiac and Pulmonary Resuscitation: Focusing on what matters.

Peter G Brindley MD FRCPC,

Division of Cri t ical Care Medicine, Universi ty of A lberta, Edmo nton, Canada

ABSTRACT

Cardiopulmonary resuscitation (CPR) has the remarkableability to prevent otherwise inevitable death. Sadly, it canalso significantly prolong the dying process, increase familyduress and patient suffering, and squander scarce resources.Attempts to revive the failing heart and lungs date backhund reds of years. However, it was not until the 196O's that

CPR was form alized.'' Fifty years on, it remains a topic ofintense study, impassioned debate, divisive opinion, andlegal consequence. It is, therefore, an important issue for allHealthcare Practitioners.

While admission to a dedicated Palliative Care Unittypically means that CPR will typically no longer be anoption, this is not the case for larger numbers of equallysick patients admitted to general hospital wards. In fact,CPR's "special status" is emphasized by the fact that it isthe only medical intervention that requires explicit docu-mentation not to be performed. Therefore, optimal com-munication cannot be overemphasized. StandardizedAlgorithms - as outlined by the guidelines for AdvancedCardiac Life Support (ACLS) - remain the recommendedway to perform CPR. Guidelines are regularly updated,and widely taught.'̂ "'' As such, it is comparatively simple toproceed with CPR. It is far more important to decide uponits appropriateness.

This review will therefore focus on prognostic factors inorder to promote communication and advocacy. The intentis not to dictate who must (or must not) receive CPR.Instead, it is to provide baseline knowledge in order toencourage informed dialogue with patients and families.Only in this way can we deliver empathetic patient-centered care, even where the research is imperfect or the

emotions extreme. The goal of CPR should be to extendlife, not to prolong death.

RÉSUMÉ

La réanimation cardiorespiratoire (RCR) présente la capacitéremarquable d'empêcher un décès autrement inévitable.Malheureusement, elle peut aussi prolonger l'agonie,augmenter les contraintes imposées à la famille et lessouffrances du patient et gaspiller des ressources précieuses.Les efforts de réanimation des fonctions cardiorespiratoiresremontent à des centaines d'années. Ce n'est cependant quedurant les années 1960 que la RCR a été structurée'\Cinquante ans plus tard, la RCR demeure un sujet d'intensesétudes, de débats passionnés, d'opinions divisées et deconséquences juridiques. Il s'agit donc d'un enjeu importantpour les professionnels de la santé.

Si l'admission dans une unité de soins palliatifs signifiehabituellement que la RCR n'est plus une option, ce n'estpas le cas pour un grand nombre d'autres patients toutaussi gravement malades admis dans les unités de soinsréguliers. En fait, le « statut particulier » de la RCR estaccentué par le fait qu'il s'agit de la seule interventionmédicale qui exige une documentation explicite pour ne

pa s être exécutée. Par conséquent, on ne peut trop insistersur l'importance d'une communication optimale. Les algo-rithmes normalisés — énoncés dans les directives sur lestechniq ues spécialisées de réan ima tion cardiorespiratoire -restent la façon recommandée de pratiquer la RCR. Lesdirectives sont mises à jour régulièrement et largementenseignées"^'. À ce titre, si l'utilisation de la RCR estrelativement simple, il est beaucoup plus important d'endéterminer le caractère approprié.

Cet examen mettra par conséquent l'accent sur les facteurspronostiques, de façon à favoriser la communication et lapromotion. L'intention n'est pas de dicter qui doit (ou ne

doit pas) bénéficier de la RCR. Il s'agit plutôt de fournirdes connaissances de base afin de favoriser un dialogueéclairé avec les patients et les familles. Ce n'est que de cettefaçon que nous pourrons offrir des soins empathiques centréssur le patient, même dans les cas où les recherches sontimparfaites ou l'émotivité extrême. Le but de la RCR doitêtre de prolonger la vie, pas de prolonger l'agonie.

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Abbreviations (alphabetically):

Advanced Cardiac Life Support (ACLS)

Asystole (ASY)

Cardiac Arrest (CA)

Cardiopulmonary resuscitation (CPR)

Coronary Care Unit (CCU)

Do not resuscitate (DNR)

In hospital (IH)

Intensive Care Unit (ICU)

Operating rooms (ORs)

Out ofHospital (OH)

Pulseless electrical Activity (PEA)

Restoration of spontaneous circulation (ROSC).

United States (U.S.)

Un-witnessed cardiac Arrest (U W CA)

Ventricular ibrillation (VF)

Ventricular tachycardia (VT)

Witnessed cardiac arrest (W CA)

BACKGROUND

Up to 750,000 CPR attempts occur annually in the United

States (U.S.)' and the cost of unsuccesful efforts exceeds

$1 billion U.S.' Of note, at least 70% of North Americans

die in Hospital, and 25% of these occur in Intensive Care

Units (ICU s).'" This m eans that, in No rth America, deathhas become an institutionalized experience and is intimately

associated with technology. Fu rthermore, CPR is an expecta-

tion for anyone without explicit contrary documentation "

and many physicians feel pressured to offer CPR regardless

of patient factors. Equally, many are reluctant to stop CPR

once they have started. However, reliable prognositicators

are available to help determine whether to start and when

to stop.

As will be outlined, the greatest determinants of outcome

are: whether the arrest was witnessed; the initial arrest type;

and how long until restoration of spontaneous circulation

(ROSC). CPR for > 20 mins without ROSC is associated

with decreased survival." In fact, an arrest that is unwit-

nessed, that began as asystole, and had no ROSC after ten

minutes of CPR has a predicted mortality of 100 % ." As

such, physicians can estimate non-survival. Furthermore,

overall, it is patient factors (i.e. "who" is resuscitated)

that currently has a greater influence upon survival than

resuscitation technique or technology (i.e. "how" they are

resuscitated)

PATIENT FACTORS

Initial Cardiac R hythm

The order of "survivability" following cardiac arrest is

consistent between st udie s."'" Th e likelihood of survival isgreatest following ventricular fibrillation (VF) with

decreasing survival following ventricular tachycardia (VT),

followed by pulseless electrical activity (PEA) and is lowest

for asystole (ASY). Strong co-linearity also exists between

the arrest type and whether an arrest is witnessed, namely

most ASY/PEAs are un-witnessed and most VF/VT are

witnessed."' " Understandably, more in-hospital cardiac

arrests (IH CA) are witnessed compared to out-of-hospital

cardiac arrests (OH CA). However, what is concerning is

that > 40% of all in-hospital arrests are still unwitnessed.

and 2/3rds of in-hospital arrests are currently ASY/PEA

"(see below). This is a large part of why survival following

cardiac arrest has not improved for the general hospital

population despite 40 years of medical advances.""

Primary respiratory arrest (RA) versusprimary cardiac arrest (CA) versus

In contrast to cardiac arrests, survival following primary

RAs is significandy higher. Greater than 40% of respiratory

arrest patients (i.e. requiring intubation but no need for

chest compressions/defibrillation) survive to be discharged

home." This compares with less than 15% discharged

home following unwitnessed cardiac arre st.'" This difference

is presumed to be because, by responding to RA, full

cardiac collapse is avoided. As a result of the different

survival rates, for some patients, it is appropriate to recom-

mend pulmonary resuscitation alone (i.e. intubation and

mechanical ventilation), but not full CPR (i.e. intubation

plus chest compressions and defibrillation). This means

patients still receive rapid attention, and ICU/CCU transfer,

while at the same time avoiding potentially futile therapy.

This also facilitates treatment of reversible illness and ade-

quate attention to symptom control such as discomfort or

dyspnea. This also prevents a do-not-resuscitate order

(DNR) being misconstrued as "do-not-respond". This

"middle-ground" may be reassuring to families who might

otherwise misconstrue a DNR to mean patient neglect, or

the false impression that the medical staff are simply

"giving-up".

The Association Between Age, Co-Morbidit ies,and Survival

Several studies have reported an association between

advanced age and poor survival following CPR, 14 but just

as many have not. 11This raises the adage familiar to clini-

cians of the contrast between "the good 80 year-old" and

"the bad 80 year-old", and introduces the potential influ-

ence of co-morbidity upon survival.

Many studies have found an association between being

house-bound/functional dependant and significantly

decreased survival following cardiac arrest.'^™ Similarly, for

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elderly Nursing Home patients, survival is very poor with

most studies reporting < 5% survival following CPR and

<1 % survival for unwitnessed Nursing Home cardiac

arrestSi'''̂ ''̂ ^ However, almost 3 0% of N H patien ts receive

CPR following un-witnessed arrests.^'' Even with on-site

ACLS-trained physicians, and defibrillators, there was no

significant survival improvement?''" Authors have thereforerecommended not offering ACLS in this setting.^'

Bedell et al. did fmd an association between decreased

survival and renal failure, congestive heart failure, sepsis,

hypotension, pneumonia and cancer." However, there is

also disagreement in the literature regarding the influence

of co-morbidities. For example, a Canadian multivariate

analysis failed to find a significant association between sur-

vival and the presence of malignancy, sepsis, myocardial

infarction, ptieumonia, renal failure or hypotension.'^

There is also a common assumption that those with

cardiac illness who suffer a primary cardiac event are more

likely to survive than those with non-cardiac illness (i.e.pneumonia) who then suffer a cardiac arrest.'^ Despite the

apparent common sense that patients with single organ

disease are likely to do better than those with multi-organ

dysfunction, again the literature raises doubts. In a

prospective study, Doig et al. found that survival was not

significantly lower for those with four or more active

medical problems versus three or less.'^ Definitive conclu-

sions are likely complicated by differing study design and

disease definition, but disappointingly there is insufficient

evidence to definitively predict the outcome solely based

upon pre-existing illness or advanced age. In contrast,

consistent evidence exists linking the location of a cardiac

arrest with survival.

LOCATION OF CARDIAC ARREST

Out of Hospital Cardiac Arrest (OH CA)

OH CA has significantly lower survival compared to in-

hospital (IH) CA.

This is likely because delay in CPR is a significant

predictor of death. Therefore, if patients arrive in ASY

despite OH CPR, many authors advocate ceasing CPR

immediately.'-"^" Similarly, it has been recommended to

withhold CPR,^' or not to exceed ten minutes," fot un-

witnessed OH ASY. Furthermore, un-witnessed OH PEA

with CPR greater than five minutes appears uniformlyfatal.^' The Ontario Prehospital Advanced Life Support

(OPALS) Study is the largest OH CA multi-centre study

(17 cities, 1 8,000 cases) and found that survival to hospital

discharge was roughly 5.0 %.'° Interestingly, a Danish

study reported an impressive 8.7% survival-to-discharge

for O H arrests (and A&Vo survival to ten years).̂ ' However,

this pre-hospital system includes dispatched physicians

who decided whether or not to perform CPR. Of note.

> 50% patients were not offered CPR. This selection bias

reduces the study's generalizability at the same time as

emphasizing the impottance of who is resuscitated upon

survival.

In-Hospital (IH)

Survival to discharge following IH CPR for the general

hospital population (and excluding those admitted to

ICU/CCU) is typically <1 5 %. " ' ' Canadian data showed

that, despite 40 years of medical advances, survival follow-

ing IH CPR has not significantly improved, with 13.4%

survival to ho spital discharge." O f no te, however, even this

may represent a "best-case scenario", as the hospital studied

were large tertiary-care urban hospitals that possessed 24hr

"code teams", and Intensive Care (ICU) and Coronary

Care Unit (CCU) back-up. This is in stark contrast to the

lesser resources of rural hospitals. However, for the sur-

vivors, neurological recovery is often acceptable with >

50 % of both adult and pédiatrie survivors maintain satis-factory cerebral performance."'^^

Survival to discharge following CA in ICU/CCU is as

high as 30%.""* This nearly two-fold survival improvement

when compared to general hospital inpatients is believed to

be because arrests are witnessed and resuscitation begins

almost immediately." As such, many hospitals wish to

increase the numbe r of mon itored beds. Many hospitals are

also focusing on ensuring rapid response with the hope of

early identification and stabilization of patients in order to

prevent full cardiovascular collapse. Regardless, this data

emphasizes the importance of early response and also

whether an arrest is witnessed.

Witnessed Arrests (WA) versus U nwitnessed

Cardiac Arrests (UWA)

As stated above, survival is significantly higher following

a WA, as compared to a UWA." To put this into stark

contrast, in the above mentioned Canadian study when

WA and UWA were combined approximately l-in-3 had

R o s e , l-in-7 survived to hospital discharge, and 1-in-lO

returned to independent living. This is in contrast to the

45 % of arrests that were unwitnessed where only one-fifth

had R o s e and where nobody survived to discharge.

In contrast for the 55% of arrests that were witnessed

approximately l-in-2 still achieved ROSC, with l-in-3survival to 24 hrs; l-in -4 survival to discharge, and l-in-5

were able to return home."

OT HER ISSUES

Surgery for patients with pre-existing DNRs

Many physicians are unsure what to do when the patient

with a DNR order requires surgery. This is relevant as up

to 15% of patients with pre-existing DNR orders currently

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receive operations." Reasons include relief of

obstruction/pain; feeding tubes; tracheostomies etc. Most

hospitals, appropriately, suspend DNR orders for the peri-

operative period. Reasons include because routine periop-

erative managem ent usually requires cardiopulmonary su p-

port (i.e intubation for surgery), because routine recovery

from the perioperative insult m ay require an IC U stay; andbecause operating rooms are inadequate for family visita-

tion and bereavment if death occurs. Obviously issues

remain as to what constitutes an appropriate peri-operative

period such that the DNR may be re-instated. However,

for all of these reasons, preemptive on ongoing communi-

cation is required in order for the patients wishes to be

respected and for the OR staff to feel comfortable to proceed.

COMMUNICATION

Therapeutic efforts should continue to improve outcome

following CA.^^"

However, the inevitability of eventual death means com-munication will always be paramount. Unfortunately,

many physicians are reluctant to address resuscitation wish-

es. Even more concerning is that educational initiatives

have n ot significantly improved this.̂ "̂ There is also poor

agreement between the beliefs of doctors, families, and

patients, and inadequate communication is a frequent

cause of conflict.^'

In a novel review of cardiac arrests on television. Diem et

al. found survival to be over 60%. ' ' This is two to four

times the actual survival rate. However it may represent the

expectation of the lay public, at the same time that televi-

sion may minimize the true consequences of attempted

resuscitation. Regardless, it means that a useful starting

point is to ask about patient's and families' assumptions.

Equally, many physicians may be overly pessimistic regard-

ing outcome following CPR. Therefore, it is our hope thatthis manuscript provides sufficient objective information to

stimulate meaningful discussion. Overall, communication

is central to Medical Care, and to patient and family satis-

faction." It appears that much work remains to be done.

CONCLUSION

Only three factors have been consistently associated with

increased survival witnessed arrest (as c/t to un-witnessed

cardiac arrest); VF/VT as initial cardiac rhythm (as c/t

ASY/PEA); and restoring spontaneous circulation within

20 mins (i.e. not offering prolonged CPR).

Laudable efforts to increase survival will continue.However, this mandates ongoing debate about when this

offers a chance for "better life" and when it threatens a

"worse death". Technological advances must not supplant

open communication, nor can they replace individualized

decision-making. In short, "technology" must not replace

"humanity". Few specialties understand this better than

Internal Medicine. As such, its voice is needed now and in

the future.

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Correspondence to:

Dr. Peter Brindley, Associate Professor and Residency Program Director, Division of Critical Care Medicine, Unit 3C4, Walter C. Mackenzie Centre

University of Alberta Hospital, 8440-112 Street, Edmonton, Alberta T6G 2B7, Canada

Tel: (780) 407-8822 Fax: (780) 407-6018 Email: [email protected]

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