Medical Orders for Life-Sustaining Treatment - Professionals
Cardiopulmonary resuscitation (CPR) is intended to prevent sudden, unexpected death.
CPR is not indicated in cases of:
1. Terminal, irreversible illness where death is expected, or
2. In certain medical situations where CPR is deemed ineffective.
For many people resuscitation is unwanted, unneeded and impossible. Depending on the situation and the person’s preferences, CPR may be inappropriate, futile and undignified.
Studies have shown that physicians speak 75% of the time and use medical jargon. Further studies reveal that after discussions related to cardiopulmonary resuscitation, 66% of individuals did not know that many patients need mechanical ventilation after resuscitation, 37% thought ventilated patients could talk and 20% thought ventilators were oxygen tanks. i,ii
Survival rates in the community are poor. A study in the Rochester community of 1177 out-of-hospital cardiac arrests showed a 5% survival to 1 year. Logistical regression identified younger age, CPR initiated by a bystander or first responder and presenting rhythm of VF/VT was associated with survival to 1 year. iii
Physicians tend to overestimate the likelihood of survival of in-hospital cardiopulmonary arrests to hospital discharge. The literature reports an average survival rate of 15%. At least 44% of the survivors have significant decline in functional status at the time of discharge. iv,v
Improved survival rates with good functional recovery are reported with duration of CPR shorter than 5 minutes and CPR occurring in the ICU. vi
Poor outcomes at all sites of care are associated with unwitnessed arrest, asystole, electrical-mechanical dissociation, greater than 15 minutes of cardiopulmonary resuscitation, metastatic cancer, multiple comorbidities and sepsis.
Chronic illness, more than age, determines prognosis in the elderly; elderly with chronic illness have an average survival rate of less than 5%. For those with advanced illness, survival rates are often less than 1%. vii, viii, ix For example, bedfast patients with metastatic cancer, who are spending fifty percent of their time in bed, have a survival rate of 0-3%.
Experts speculate that survival rate misconceptions are further complicated by the fact that 67% of resuscitations are successful on television. Attempts to educate patients are successful. In one study of 371 patients, age greater than 60 years of age, 41% wanted cardiopulmonary resuscitation. After learning the probability of survival, only 22% wanted cardiopulmonary resuscitation. x, xi
Statistics to keep in mind when having discussions about CPR:
• Survival rate of CPR on television shows: --> 66%
• Actual in-hospital survival rates for CPR:
All hospital patients: -------------------------------> 15%
Frail elders*: -----------------------------------------> <5%
Individuals with advanced chronic illness**: -> <1%
* An older person that has troubles performing activities of daily living because of weakness or fatigue is more vulnerable to acute illness due to low activity level.
**Advanced chronic illness such as Alzheimer’s, Parkinson’s or end-stage heart, lung or kidney disease.
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