MGordon_MD
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Mar 22, 2007, 9:10 AM
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Time to Rethink Resuscitation in the Elderly
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By Dr. Michael Gordon
The daughter insisted, “You have to do everything for my mother including CPR. I cannot forgo any chance that might keep her alive.”
This occurred during a meeting with her mother’s health-care team where the reality of cardio-pulmonary resuscitation (CPR) in the frail nursing home population was discussed. Similar conversations occur with families of nursing home residents across North America, to demystify what CPR is and what it potentially can and realistically cannot accomplish for their loved one.
One common misunderstanding is that CPR brings a person who has died back to life, and for some families, this is a religiously based imperative and obligation. Another misunderstanding is that CPR is very successful in reviving people who have suffered a cardiac arrest. A third is that CPR itself is relatively innocuous, and therefore, there is no reason not to attempt it.
In some circumstances, CPR, when undertaken rapidly with relatively younger and healthier people, can prevent a death from occurring as a result of a cardiac arrest (stoppage of the heart), if that happens in the context of a healthy or at least effectively functioning heart. For example, CPR may be successful in cases of electrocution or drowning, when the person is retrieved quickly, or during a heart attack when the heart muscle is injured, but potentially retrievable and functional through rapid medical treatment.
In frail elderly people, however, the event causing cardiac arrest is usually due to multiple serious diseases that, combined, result in the heart’s stoppage, which cannot be reversed by CPR.
As for CPR survival, some years ago, the highly reputable New England Journal of Medicine published an article titled, Cardiopulmonary resuscitation on television: Miracles and misinformation, in which researchers analyzed CPR on three popular television programs – ER, Chicago Hope and Rescue 911. All instances of CPR in 97 episodes were recorded. There were 60 occurrences of CPR in those episodes. Seventy-five per cent of the patients survived the immediate arrest, and 67 survived to hospital discharge. The study’s authors noted that the survival rates were significantly higher than the most optimistic actual survival rates in the medical literature, and the portrayal of CPR on television has led the viewing public to have an unrealistic impression of CPR and its chances for success.
From this and other studies, it is clear that the public is not accurately informed about the effectiveness of CPR. This creates a situation in which people may choose CPR for themselves or for family members when survival, not to mention recovery, is unlikely. In the frail elderly in a nursing home, the actual survival rates hover close to zero, with only rare instances where survival of CPR and recovery occur.
The last important question that families often ask is why not try anyway, on the remote chance that success will be achieved? CPR is an invasive, traumatic and undignified procedure. If survival is a meaningful or substantial possibility, of course it is justified. But if not, why subject your loved, frail elder to a dreadful end-of-life experience? Even for those for whom sanctity of life for religious reasons is paramount, the likelihood of a life being saved is very remote. CPR in this population contradicts the concept of a gentle death, which should be one of the major goals of families and of medical practitioners.
For caring families, the long-term care experience should focus on interventions that can assure comfort and a sense of worth. Looking to high-tech miracles to avoid inevitable death is unlikely to succeed and may impose an ineffectual technological intervention into what should otherwise be the naturally occurring and dignified process of dying.
This article was originally published in the Canadian Jewish News.
Dr. Michael Gordon, is vice-president of medical services at Baycrest in Toronto, Canada, and co-author with Bart Mindszenthy of Parenting Your Parents.
Parenting Your Parents is available in bookstores and online at: Indigo-Chapters, Amazon and Barnes & Noble.
For bulk orders email info@dundurn.com. Call: 416-214-5544 or Fax: 416-214-5556
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(This post was edited by MGordon_MD on Sep 24, 2007, 1:36 PM)
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