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DNR/DNI, oh my! The lowdown on CPR in older adults- does it really promote a death with dignity?

In the last blog, I had spoken a bit about dignity- the preservation and respect for self in the context of dementia. This week, I wanted to explore another area where dignity comes up- perhaps a bit more difficult to think about- death. And specifically about what we do to many older adults when they die- cardiopulmonary resuscitation (CPR).

Please note that this entry contains some pretty blunt statistics and scenarios. If you feel it might be difficult to read through them, consider holding off.

Most of America, if not the world, pictures their ideal death as one at home,- surrounded by loved ones, warm, peaceful, pain free, and quiet. However, the statistics show that most people in this country die in the hospital setting- stripped of their comfortable clothes, not in their own bed, with unfamiliar doctors, nurses and other healthcare personnel surrounding them, and in a loud, uncomfortably bright, and often cold environment. Additionally, many older adults undergo CPR at the time of death to try and resuscitate them "back to life."

CPR has been described in the medical literature dating back to the late 1800s when closed chest massage was outlined. However, it was not until the late 1950s/early 1960s that Kouwenhoven described a procedure using closed chest massage to resuscitate patients who had undergone cardiac arrest in the operating room. As this technique evolved, it was initially applied to a younger groups of patients, often suffering cardiopulmonary arrest (i.e. a complete stop of heart rate/rhythm & breathing) in the context of some traumatic event- lightning strike, drowning, etc. Success rates were pretty good initially, but mostly because the patients being resuscitated were younger and healthier. However, over time, CPR has expanded to include older patients, often with multiple chronic medical conditions, functional impairments, and even cognitive declines. The success rate in this group is much less than most people know or accept.

When looking at cardiac arrest and outcomes of CPR in older adults (particularly those with multiple medical problems, functional impairments, and/or cognitive problems), most studies have used 2 settings. The first is an out of hospital arrest- that is, the person suffers a cardiac arrest outside a hospital setting. This could be at home, at a store, or even in a doctor's office. IF this event is witnessed by someone who KNOWS CPR and starts it immediately along with triggering the appropriate chain of events in time, the chances of an adult over the age of 70 surviving to hospital discharge is...5-7% at best. So, this could be the scenario if you were out shopping with your older relative or friend and s/he collapsed because of cardiac arrest in front of you. And remember, this outcome assumes that all the events and techniques of CPR were carried out as they have to be.

So, what happens if this older adult is admitted to a hospital and has a cardiac arrest there? Even in this situation where trained health care providers witness the event & trigger the appropriate "Code Blue" chain of events, the survival to discharge for an adult over the age of 70 is at best 10-12%, some studies saying up to 17-18%.

All this being said, that means 85-90% of adults over the age of 70, DO NOT SURVIVE CPR. And of the 10-15% that do, 40-50% of them are functionally & neurologically worse off than before the event- meaning that most likely, they are less able to live independently, return to home, or think clearly for themselves. Remember, one of the goals of CPR is to maintain blood circulation to vital organs, especially the brain. And the brain uses ONLY oxygen & glucose for its metabolism- if these two sources are gone for even 2-4 minutes, parts of the brain start undergoing irreversible damage and death.

If you look at a population of older adults who reside in a nursing home & undergo cardiac arrest, most studies indicate that 0-2% survive to hospital discharge.

Why are the numbers so low?!?!? CPR looks like it helps everyone on TV!

And therein lies one of the major problems. Outcomes of CPR on TV shows like ER, Chicago Hope, Grays Anatomy, Rescue 911 have been studied several times. In these studies, 66-75% of adults (notice I say adults, not OLDER adults) survive to discharge. BUT- who gets resuscitated on these shows? Often, it's a younger victim of some traumatic event that generates drama- electrocutions, drowning, gunshots, motor vehicle accidents, lightning strikes. Furthermore, this younger victim often has no other medical problems, is likely completely independent in their ability to care for themselves, & has no cognitive or memory impairment. I ask you now- how many times do you see an 87 year old patient with diabetes, high blood pressure, heart failure, memory loss, arthritis and difficulty managing themselves get resuscitated on these shows? Probably ZERO. And that's because in reality, the outcomes for their survival to discharge is much lower as noted above.

There are several reasons older adults, and especially those with multiple medical, functional, & memory problems don't do as well after CPR. Firstly, the heart often "arrests" or stops beating when it undergoes some type of stress that triggers it to go "kaput." Some of these triggering events are problems with the heart's rhythm- you may have heard of conditions called ventricular fibrillation (V Fib) or ventricular tachycardia (V Tach)- where the main chamber of the heart is beating erratically and fast due to abnormal electric impulses. These rhythms & triggers can sometimes be "shocked" back to normal. However, older adults tend to have these rhythms less and more often have something called "pulseless electrical activity" (PEA) which means that there is some type of electrical impulse in the heart, but it's generating no pulse. This rhythm is notoriously resistant to shocking and often very difficult to convert to a functioning heart rate.

Also- many older adults suffer chronic medical conditions such as coronary artery disease, prior heart attacks/conditions, heart failure, high blood pressure, etc. that make it harder for the body to rebound from an acute stress- especially one that stops the heart from beating. And finally, as we age, even without disease, it becomes harder for the body's systems to launch a coordinated attack to an acute stress- meaning we recover from an acute stress or injury much more slowly than when we were younger. This is a natural part of the aging process. Think of how much longer it takes you & your body to get over the common cold as you get older.

On top of the low survival rates in older adults along with the poor functional and neurologic consequences after CPR, one has to also consider the immediate consequences. Remember, to effectively massage the heart from the outside & maintain good circulation, we have to push down on the chest wall ~2 inches at least 100x/minute. This can result in significant bruising, breaking of ribs/bones, puncture of the lungs or linings of the heart, and of course, pain. On top of that, think about getting up to 300 Joules of electricity shocked through you without any anesthesia, pain medication, or sedation. CPR is an EMERGENCY intervention and done without any anesthesia, pain medication, or sedation.

And coming back to dignity- if you need CPR, you will be stripped and exposed in order for the teams to be able to do the procedure effectively. So that could be on the floor of Target in front of everyone who is there, in the parking lot of Shop Rite, or in a cold emergency room surrounded by strangers and other sick patients. People will see your chest compressed, electric shocks applied, catheters inserted, intravenous lines placed, and tubes put down your mouth/throat.

All this being said, there is a way to avoid this and "allow a natural death" if that is a patient's wish. It's called a DNR (do not resuscitate) order & is something that has to be discussed between a licensed healthcare provider and patient. Furthermore, a DNR needs an order signed by a licensed healthcare provider. If you don't have a DNR order, the default in the event of a cardiopulmonary arrest is CPR as described above.

But, many patients & families confuse a DNR with "do not treat." And that is something I always have to emphasize and clarify- DO NOT RESUSCITATE DOES NOT MEAN DO NOT TREAT! A DNR order applies ONLY to the situation of a cardiopulmonary arrest (i.e. the heart & lungs have completely stopped working, there is no pulse/breathing, the person is dead.).

You can have routine medical & surgical treatment with an active DNR order. For example- you can still get chemotherapy for cancer, blood transfusions for anemia/bleeding, intravenous antibiotics for an infection, an endoscopy or colonoscopy, a pacemaker for an irregular heart rate, and even surgery. You can get oxygen support by prongs, masks, or other devices that don't involve putting a tube down your mouth/throat & connected to a ventilator. You can get care in the intensive care unit & receive medications to support your blood pressure or control your heart rhythm better. You can even get a cardiac catheterization- remember cardiac arrest is NOT the same thing as a heart attack (though heart attacks can lead to cardiac arrest). The only time we hold back on medical procedures or interventions is when or if your heart & lungs completely stop.

I get asked, "So if mom/dad have a cardiac arrest and they have elected to have a DNR order, do we just leave them there to die & do nothing?!" We don't just leave them there. Consider that, rather than forcing them to undergo a pretty undignified, cold, & painful intervention, we can provide them warmth, pain control, peace, & a gentle transition that doesn't subject them to aggressive chest compressions, stripped clothes, electric shocks, needles and catheters, and pain. And remember also that if the older adult is medically or functionally frail, their outcome will likely be poor and they will most likely not be living the quality of life they wanted. That is, independently going to family functions, managing their personal care on their own, not being connected to tubes and drains, or worst of all- not living at home anymore.

When I ask patients about what's important to them, what are their goals for care- they often say, to allow death naturally, to preserve quality of life, to not have pain, to not be a burden of care on their loved ones, to be able to garden or go for a walk or attend a special event. Well, it's time to think about how these things may not be realized after CPR. For the small percentage of older adults with significant medical problems, etc. who survive- life most likely means time in a nursing home, being dependent on others for personal care, and needing tubes/drains/catheters...not the happy independent walk in a garden with a loved one.

So, if you are an older adult with multiple medical problems, consider having a discussion with your healthcare provider about this issue. Weigh the risks, benefits, and options for care in detail. And understand that a "DNR" is not giving up on treatment or "throwing the towel in." I think it can be a way to respect a natural death (and death comes to us all) and preserve dignity at a very sensitive time.

At Geriatrics Planning & Solutions, Inc., we can help you assess your medical, functional, & cognitive situation and support you through these difficult conversations to come to a decision that makes sense for you.

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