The Filthy Secret About CPR in the Hospital (That Doctors Desperately Wish You to Know)

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Source:   —  April 13, 2016, at 1:24 AM

Okay, a lot has changed, and most of it good. But along with the improvements in patient care there has been an exponential expand in expectations.

The Filthy Secret About CPR in the Hospital (That Doctors Desperately Wish You to Know)

A few things have changed in medicine over the latest few decades. Okay, a lot has changed, and most of it good. But along with the improvements in patient care there has been an exponential expand in expectations. We've somehow gone from "your loved one has a life threatening illness and we'll do what we can to treat it and in the meantime ensure they don't suffer" to "your loved one has a life threatening illness that we've the capacity to cure, and if we don't we'll have done something wrong."

The problem is, latest I checked, everyone dies. Let me declare that again for excellent measure. Everyone. Dies. The problem isn't with that truth alone, but with the fact that patients with terminal illnesses -- and their caregivers -- seldom realize their mortality. And when patients and families have unrealistic expectations about what their doctors can accomplish, many people die in a way they never planned for or wanted: in the hospital, dependent on strangers for the basics such as eating and bathing, and frequently hooked up to machines.

If that makes you perceive hopeless, you're not alone. Many doctors and other health care professionals I work with perceive that way, too. In the hospital, your code status -- whether you wish to be resuscitated or not when your heart stops -- has become a sort of surrogate for determining whether you really realize your prognosis. Of course, it'south not quite that simple. We know there are other considerations, such as deeply ingrained core values and past experiences with death -- excellent or bad -- that play into a patient'south wishes about their death. But the hospital is frequently the worst space to start to have these necessary conversations. Patients in the hospital are sick, they're scared, and they generally have number prior relationship with the physician who's trying to paint a realistic picture of their condition.

Everyone in health care -- assuming they don't have their head in the sand -- knows that the system, particularly regarding finish of life care, is terribly broken. While I believe we're on the path to improving this (within the latest year, Medicare approved payment for voluntary end-of-life counseling), we still have a long way to go. But there are things patients can do to get back control of their health and the health of their loved ones.

one. Realize What Resuscitation Is

It nearly uniformly involves chest compressions, intravenous medications, mechanical ventilation, and defibrillation. Currently, resuscitation is performed unless a patient has "opted out" in the form of a DNAR order (Don't Attempt Resuscitation). Many people in health care perceive that resuscitation should be approached love any other procedure in medicine, requiring consent from a patient to begin it in the first place. And in the case of resuscitation -- when the patient and family goal isn't only survival, but a return to prior level of functioning -- the chances of success are alarmingly low. After all, if a Dr offered you a surgery that'd a 1.7 % chance of improving your condition, was painful and distressing, and had to be done without sedation or pain control of any kind, you may just select not to proceed.

Patients and their family members are frequently presented with the ever-important "code conversation" in the following way: "If your heart stops or you stop breathing, do you wish us to do everything?" For a doctor, it'south a lazy way of asking, "Would you wish to be resuscitated?" without explaining precisely what that entails. But what patients frequently hear is: "Do you wish us to do everything or nothing?" or, worse: "I think you might die during this hospitalization."

Of course, neither of those things is what the physician is really trying to convey with this question. First, there is a lot we can proposal in the way of treatment brief of resuscitation. Many times, our treatments are able to get round the necessity for resuscitation altogether. And, even if death is unavoidable, there is so much we can proposal patients and families to reduce suffering and allow support. We, as a society, frequently equate doing "everything" will showing our love. ("I'll never let mom die.") Many times, nothing could be farther from the truth. As people age and their chronic illnesses progress, quality of life -- rather than quantity of time -- should be the central focus. But, as we look too often, it seldom is. Second, we're nearly never implying that death is imminent with this question. We attempt to bring up the issue of code status with every admission. Since we don't have a crystal ball, we can't always predict a medical emergency (sometimes, yes, we beautiful much know it'south coming). But regardless, we wish to be prepared to act, at a moment'south notice if necessary, in a way that respects your wishes.

We, as doctors, as a health care system, cannot afford to be destitute communicators about this issue. But patients and families, for their parts, cannot afford to be uninformed.

two. Realize What Resuscitation Is Not

It'south not a guarantee of survival, and it'south certainly not a guarantee of survival with the same quality of life you enjoyed previously (or even a quality of life you deem acceptable). We'll speak about this concept a tiny more below.

Codes aren't what Hollywood would've you believe. One study in which the researchers watched ninety-seven episodes of favorite medical dramas in the one thousand nine hundred ninety reported a seventy-five % survival rate for fictional patients immediately after resuscitation and sixty-seven % survival rate to hospital discharge. In stark contrast, an article in the Journal of the American Medical Association published in two thousand-thirteenth studied a prediction tool for survival after in-hospital resuscitation. In it, they used four department points to stratify patients' chance of survival with a meaningful quality of life: very low (three-fifteen percent) and higher than average (>fifteen percent). That bears repeating. A higher than average success rate for ACLS was >15 percent.

Presented another way, the average chance of successfully resuscitating a young, healthy person (when success means the patient is neurologically intact, i. e., not physically or mentally dependent on others) is only thirty percent. The average success rate of resuscitation in an elderly nursing residence resident with several chronic medical issues (who may have even been going along just fine prior to their illness) is 1-3 percent. For some patients, the success rate approaches zero.

3. Realize Your Health

A young, previously healthy person with a treatable (i. e., fixable) condition is the poster baby for resuscitation. Nearly everyone else is not. That'south not to declare we should never attempt CPR in the hospital, but there are many cases when it's clearly the incorrect thing to do. In the end, it's an individual decision that each person should create with the assistance of their doctors and other health care professionals. But patients should be alert that many chronic medical conditions, such as dementia and COPD, negatively affect their chance of surviving an in-hospital cardiac arrest, and patients should know what they're getting into. Complications such as kidney damage, liver damage, low blood pressure, and mental status changes also worsen your chances of surviving. Increasing age, as you might imagine, does, too. This isn't the only thing to consider when deciding or updating your code status, but you cannot create an informed decision without this knowledge.

four. Realize the Risks of Resuscitation

The risks? Wait, I thought resuscitation was good, that it was supposed to rescue lives. Sure, it's and it does... sometimes. But all medical treatments have risks or side effects associated with them. It'south the inherent nature of the practice of medicine.

Long term, patients can finish up with destitute neurologic function, dependent on ventilators which breathe for them and which they've number hope of coming off of because of their previous lung sickness or other complicating medical issues. Even if not dependent on a ventilator, they may require feeding through tubes introduced into their gut because they aren't able to swallow. They can be bedbound and expand ulcers on the dependent areas of their bodies. These ulcers can become infected. They're frequently tied down to hold them from pulling at their numerous tubes due to their delirium. They obtain urinary tract infections because they require a foley catheter or are incontinent.

Many families perceive trapped after their loved one has "beaten the odds" and survived a cardiac arrest just to be in a situation similar to the one described above. It's necessary to mention that it'south never too late to withdraw care in these situations. This isn't equivalent to causing death, as the underlying illness is doing that. It's simply removing the artificial means of keeping the patient alive.

Death is an inevitability. Modern medicine is incredible in that we can frequently treat the complications of terminal disease. But we cannot modify the terminal nature of those diseases. And when the treatment starts to cause more damage than good, we necessity to get a step back and re-evaluate our goals. One of the most incredible things about medicine, one of the reasons I like practicing, is the experience we gain over the years. We can counsel a patient who may be experiencing illness for the first time on what to expect -- because we've seen it. No, we can't tell them the day and the hr of their death, but we can give them an idea of how things are going to go, so they can determine on their own terms when sufficient is enough.

And it'south different for every person. We know that. And we respect that.

five. Fill out a Five Wishes or MOST Form and Speak About Your Wishes with Your Loved Ones

Near your eyes and picture how you imagine your death. Is it surrounded by family members in your own home? Is it on a tropical island with a Mai Tai in your hand? Is your pastor at your bedside saying a prayer over you? Chances are, it's not tied to a bed in a freezing hospital room, sedated and unaware.

Of course, many people don't obtain to control how they die. They die in car accidents or of a heart attack in the center of the night. They aren't even alert that life is passing from them during their final moments. But if you're blessed sufficient to have time to ponder your mortality and the skill to dictate the terms of your death -- wouldn't you wish to get advantage of that? A Five Wishes or MOST form tells those who'll care for you and who'll create decisions for you what those decisions should be. Gift your family with your wishes so they know how to get care of you in the way you envision.

Too often, caregivers are placed in the impossible situation of guessing what their loved ones would've wanted. Though they arrive from a well meaning place, they generally do everything to hold their family member alive, even if it prolongs a quality of life inconsistent with who they were in life (and one they'd never wish for themselves). Get the time to speak with your family and document your wishes -- and you just may finish up with that Mai Tai, after all.

The finish of life is a portion of life. It should be portion of our legacy, not a desperate last-ditch effort to escape the inescapable. Speak to your family and your Dr presently and on a regular basis as your condition changes. Get control of your legacy.

***

The information for this article was obtained from review of the articles below and conversations with Alisha Benner, MD, who's conducted research regarding end-of-life care.

http://www. cnn. com/two thousand thirteen/seven/ten/health/cpr-lifesaving-stats/

http://www. theguardian. com/society/two thousand twelve/feb/eight/how-doctors-choose-die

http://archinte. jamanetwork. com/article. aspx?articleid=one million seven hundred thirty-five thousand eight hundred ninety-four

http://www. hhnmag. com/articles/3656-health-care-costs-and-choices-in-the-last-years-of-life

http://www. cbsnews. com/news/the-cost-of-dying-end-of-life-care/

http://www. medscape. com/viewarticle/eight hundred fifty-three thousand five hundred forty-one

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