Wednesday, January 18, 2012

Is cardiopulmonary resuscitation (CPR) good for you?

Yes, I just titled this post "Is cardiopulmonary resuscitation (CPR) good for you?"

It seems like a silly question. After all, here's what the Mayo Clinic says:

Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone's breathing or heartbeat has stopped....

It's far better to do something than to do nothing at all if you're fearful that your knowledge or abilities aren't 100 percent complete. Remember, the difference between your doing something and doing nothing could be someone's life.

And the Red Cross, who offers CPR courses, strongly urges people to take them:

One quarter of Americans say they’ve been in a situation where someone needed CPR. If you were one of them, would you know what to do?

In effect, the strong message that is out there today is that CPR is a good thing, and getting trained to deliver CPR is a good thing - a matter of life and death.

But is it?

On Google+, Denise Seitz shared a link to a November 30 item from Ken Murray entitled "How Doctors Die." The main thrust of the article is that doctors, who often (for various reasons) perform extraordinary life-saving processes for their patients, often do not have such processes performed when they themselves get sick. Here's what Murray says about CPR:

Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming.

Murray didn't publish specific figures, but Robert H. Schmerling did:

As opposed to many medical myths, researchers have reliable data concerning the success rates of CPR (without the use of automatic defibrillators) in a variety of settings:

2% to 30% effectiveness when administered outside of the hospital
6% to 15% for hospitalized patients
Less than 5% for elderly victims with multiple medical problems

Murray also says the following:

[Doctors] want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Basically, if you're not breaking someone's ribs, you're probably not applying enough force. Science Daily:

New [2007] findings show that the majority of people untrained in how to perform cardiopulmonary resuscitation, and even many trained emergency personnel, do not push with enough force to properly administer CPR....

The findings showed that 60 percent of the CPR-trained rescue personnel pushed with more than 125 pounds, whereas more than 60 percent of those not trained in CPR failed to push with more than 125 pounds of force....

Pushing with more than 125 pounds increases the potential for rib fractures. Nevertheless, the chances of survival increase enormously.

So let's say that you're one of the few people who survives after CPR. After your ribs heal, do you just pop out of your hospital bed and get on with your life? Schmerling notes:

In real life, many of those who are revived by CPR wind up severely debilitated. provides more details:

Another possibility is that CPR may be only partially successful. If the heartbeat is restored but a person is still too weak to breathe on his or her own and remains too weak to do so, he or she may be on a ventilator for days, weeks, months or longer. Moreover, when breathing or heartbeat fails, the brain is rapidly deprived of oxygen. As a result, within seconds, the brain begins to fail (one loses consciousness), and within a very few minutes permanent damage to the brain occurs. If it takes more than those very few minutes to start effective CPR, the person will not fully recover. The brain damage may mean anything from some mental slowing and loss of memory to complete and permanent unconsciousness and dependency on a ventilator and sophisticated medical life support.

So why is CPR perceived as something that must be performed, when in many cases the likely result is death, broken ribs, and/or brain damage? Associate Professor William Mark Smillie of Carroll College in Helena, Montana has asked his students this question. Here is part of his presentation on the topic:

ETHICAL ISSUE: Since CPR emergency treatment often brings burden to the patient and frequently fails, when is it reasonable to initiate CPR in a clinical setting and when is it reasonable not to; and when is it reasonable for a patient to refuse future CPR attempts?

Three decades ago, when people learned how to attempt CPR, they tended to perform CPR whenever a patient suffered an arrest. This was frequently a mistake.

On the other hand, it is often hard not to perform CPR and let someone die, who could have benefited from being saved, and whose death could subject them to accusations from the family about medical negligence.

Ken Murray also addresses the issue of why doctors who refusing heroic efforts for themselves will perform it on others.

The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Murray also stated:

[D]octors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

It's a gross oversimplification to say that unnecessary lifesaving procedures are performed because of money, but money truly does play a role in these decisions. Businesses, including hospitals, often seek to avoid risk, and one of the biggest risks is the risk of litigation. Especially when the money is coming out of someone else's pocket, such as an insurance company or the Federal government, it's often better to perform medical procedures that won't work, rather than to refuse to perform unnecessary medical procedures and get sued for millions.

Murray cites an example of a patient who had a written Do Not Resuscitate (DNR) order:

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it.

If more people understood the true ramifications of CPR - both its success rate and the consequences of partially successful CPR - perhaps fewer people would treat it as the Super-Duper Survival Tool. But is a television show writer going to write something in which someone dies or is brain-damaged? Is the Red Cross going to tell people how to break ribs? I think not.
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