Ruminations

Spare No Efforts in Cardiopulmonary Resuscitation Following Cardiac Arrest in the Elderly -- Though Doomed to Fail

"It's a common scenario. And it's not going to have a good outcome."
"She was trying to die, and it was only a matter of time before she arrested again."
"Should CPR even have been started for this patient?"
Dr.Kei Ouchi, emergency physician, researcher, Brigham and Women's Hospital

"Many of us in daily practice have the perception that we regularly do resuscitations that are futile from the inception."
"We wanted to examine that."
Dr.Patrick Druwe, physician, Ghent University Hospital, Belgium

"The big ethics discussion has been around, 'When do we stop'?"
"Only recently have there been discussions about, 'When do we start it'?"
Dr.Monique Starks, cardiologist, Duke University School of Medicine, North Carolina

James Steinberg

Recently, an international network was organized by a team led by Dr.Patrick Druwe at Ghent University, for the purpose of surveying health care professionals in Europe, Japan, Israel and the United States. A study, published in The Journal of the American Geriatrics Society considered CPR for adults over 80 who had experienced out-of-hospital cardiac arrest.

The results of the study shone a spotlight on a number of issues, none very favourable, respecting physician reaction to elderly patients in cardiac arrest. The survival rates were dismal; an outcome reported previously in the medical literature. What the study pointed out was how frequently health care professionals automatically support resuscitation, despite knowing beforehand through experience that the outcome will have poor results. Results though well known to the health community are not shared with the general public.

Roughly 600 clinicians, half of whom were paramedics and emergency technicians, the remainder representing emergency physicians and nurses, were tasked with recalling their most recent patient aged 80 or more who had undergone CPR. The question put to them was whether they were in agreement with beginning cardiopulmonary resuscitation, and did they feel certain that resuscitation should not have been started, or were they uncertain?

Of the patients in the specific age category suffering cardiac arrest and immediately subjected to CPR, a mere two percent survived and were able to leave hospital. Despite which over half the clinicians felt CPR was appropriate in those instances, while only 18.5 percent felt it inappropriate. A minority of patients have a 'shockable' rhythm in cardiac arrest, where the heart is moving but abnormally and it is not pumping blood effectively.

With the use of CPR, along with a defibrillator to shock the heart, circulation can be restored and the patient's life saved. Most patients, however, have non-shockable rhythms; their hearts show electrical activity, despite which they aren't pumping at all, and in these instances survival rates tend to fall sharply. Age increases the proportion of cardiac arrests involving non-shockable rhythms.

Over 40 percent of the cases of cardiac arrest followed by CPR had been 'unwitnessed', which is to say rescuers had no idea how long the patients had been in arrest -- when reality is that the odds of successful resuscitation become increasingly diminished ten percent with each minute that passes while in cardiac arrest. Of the elderly patients with non-shockable rhythms and unwitnessed arrests, none survived hospitalization.

Irrespective of which, 44 percent of the clinicians taking part in the study felt those efforts under those circumstances, to be appropriate. Bleak outcomes following CPR for out-of-hospital cardiac arrest at advanced ages has been documented by other research, even though improvements have been seen in resuscitation results where hospitalized patients have better rates of survival.