By Stacey Kusterbeck
Emergency physicians routinely need to ask patients about their wishes for care if they go into cardiac arrest. “It has been our anecdotal experience that when we discuss these decisions, patients have a poor understanding of survival after CPR [cardiopulmonary resuscitation],” says Michelle Crispo, MD, an emergency physician at MaineHealth in Portland. Many patients had never had an informed conversation with a medical provider about CPR survival rates. “Studies that evaluate the effectiveness of CPR have documented a survival to hospital discharge ranging from 10% to 20% depending on location of the arrest,” notes Crispo. When patients receive CPR after cardiac arrest, about half of those who survive have significant neurologic damage to the brain due to the loss of circulation to the brain during the arrest.
“This can result in a quality of life which may not be acceptable for some patients,” says Crispo. When a patient is successfully resuscitated after CPR but neurologic deficits are anticipated, the decision on whether to continue life-prolonging care can be difficult. Families often feel like they are having to “pull the plug” on their loved ones, says Crispo. However, many patients would never want to be on a ventilator or life support machines, or die in a hospital. “Performing CPR with an anticipated poor outcome would put those patients at very high probability for an end-of-life scenario that is not acceptable to them,” warns Crispo.
Crispo and colleagues sought to better understand older patients’ perceived outcomes after CPR, where they get information on outcomes, and whether certain sources provide more accurate outcome data.1 They surveyed 149 emergency department patients 65 years or older. Only 7% correctly defined “code status” as whether the patient would want to receive CPR if they go into cardiac arrest.
Participants reported their information on CPR came from medical clinicians, word of mouth, personal experience, family, and television. Most participants overestimated their likelihood of survival for both in-hospital and out-of-hospital cardiac arrest. Those who received education from a medical provider were more likely to correctly define code status and to accurately predict survival.
“When clinicians engage patients in conversations about code status, it is vital that the patient has an accurate and correct understanding of outcomes of CPR,” says Crispo. The authors recommend asking patients what they know about outcomes after CPR as a starting point to assess whether the patient is basing a code status decision on accurate information. “If a patient is choosing a code status without an accurate understanding of the risks and benefits of their decision, this does not allow for informed decision-making. It would raise a clear ethical concern.”
Patients and families who overestimate the success of CPR are less likely to request do-not-resuscitate status — and that is ethically problematic, according to Jordan Potter, PhD, HEC-C, director of ethics at Community Health Network in Indianapolis. For patients, it could mean provision of medical care of questionable benefit compared to its risks, harms, and burdens. Also, it is questionable whether patients and families are really making “informed” medical decisions if they are doing so based on misinformation.
In Potter’s experience, patients and families don’t understand the true nature and purpose of CPR. Many perceive it to be a curative, therapeutic treatment. “However, CPR is not a curative treatment. It’s a bridge treatment to another intervention or recovery,” says Potter. Some patients are dying from cancer, heart failure, or another ailment leading to cardiac arrest, and there are no curative treatment options left. CPR does nothing to address those underlying disease processes. Thus, the patient remains terminal and in the dying process even after surviving CPR. “These kinds of misconceptions about CPR engender many ethical concerns in end-of-life care,” says Potter.
Many times, these issues come up in ethics consults where the primary ethical concern is the provision of futile or non-beneficial treatment, regardless of whether the concern is specifically targeted at CPR or at continued aggressive medical treatment more generally. “With a low likelihood of success of CPR, the ethical issue becomes the balance of likely benefits to risks, harms, and burdens for the patient,” says Potter. In many cases, the low chance of success of CPR combined with the patient’s overall clinical condition and prognosis leads to a determination that attempting CPR is unlikely to benefit the patient. Therefore, CPR is not medically recommended.
“Ethicists can help resolve these conflicts by assisting with clear communication about what CPR is, and, more importantly, is not, in a clear, non-technical manner,” says Potter.
- Crispo AE, Strout T, Bunting S. Older adults’ knowledge of code status and perceived outcomes after cardiopulmonary resuscitation. Ann Emerg Med 2023;82:S161.
