Almost everyone has seen the remarkable exploits of the physicians in Television’s ER, rushing to save the life of an unfortunate patient whose heart has stopped.  They are frequently called on to perform cardiopulmonary resuscitation (CPR) to restart the patient’s heart – often with great success.  For many people, television is the only exposure they have to this medical procedure and their knowledge is limited to what they see there.  However, people should be aware of the details of this medical intervention, its indications, possible benefits and inherent risks so that they may make informed decisions regarding their health care.

 

Cardiopulmonary resuscitation was developed in 1960 as a method of reviving patients who developed a cardiac arrest during an operation.  Patients on whom it was used were often young and otherwise healthy and suffered a cardiac arrest from exposure to the anaesthetic.   Since that time, CPR has become a widely practised procedure extending from the operating room to the hospital wards, emergency room and into the community.

 

Cardiac resuscitation is indicated when a person’s heart has stopped pumping blood.  This may be due to a heart condition such as a heart attack, or due to other medical illnesses, such as severe infections, lung problems, cancer or electrolyte imbalances.  If the heart stops pumping blood, no fresh oxygen will get to the brain and it will die within a matter of minutes.  In CPR, the rescuer pushes repeatedly down on the patient’s chest to squeeze blood out of the heart.  A tube is placed down the patient’s windpipe to assist in artificial breathing.  Electrical shocks are often applied to try to make the heart pump more effectively.  Intravenous medications are also used to stimulate the heart into restarting.  Family members or friends are usually asked to leave the patient as the physicians work to restart the heart.

 

Although CPR has the potential to extend an individual’s life, the chances of these interventions being successful depend greatly on the overall health of the person suffering the cardiac arrest and the speed by which it can be started.  In a monitored setting such as an intensive care unit, CPR can be started quite quickly, but in a general medical ward, a patient’s heart may have stopped for a number of minutes before he or she is found by staff.  On average in a hospital ward, CPR is only successful in 5 to 15% of times in the average patient.  This chance becomes lower if the patient is sick with other illnesses.  Conditions such as cancer, kidney failure or severe infections bring the chance of successful resuscitation down to less than 1%. 

 

If the resuscitation is successful, the patient is brought to the intensive care unit and placed on a breathing machine.  A fairly common complication of a cardiac arrest is that the patient is unable to be removed from the breathing machine and breathe on his or her own.  Other complications of the cardiac arrest and resuscitation include broken ribs, damage to the heart muscle, stroke or brain injury.  There is a chance that the resuscitated person may never wake up after the cardiac arrest.  The chance of the heart stopping again is also fairly high.

 

When people are admitted to hospital, doctors and nurses frequently ask patients what their wishes are with regard to cardiac resuscitation.  They need to ask this in advance because the patient will not be able to voice his or her opinion at the time when CPR is required.  It is often very helpful for people to discuss their ideas regarding resuscitation with their family or friends while people are generally healthy and able to express themselves.  In this way family members can voice their loved-one’s preferences if he or she is unable to communicate.  Many people also have a written record of their decision in the form of an advance directive or living will, which states a person’s preference for a number of potential treatments.  A patient’s doctors should be made aware of this document when a person comes into hospital.

 

In making a decision regarding CPR, people need to be informed as to the indications, details, success and potential complications of this procedure.  People who wish to have this procedure performed will receive the treatment if required.  People who decide not to choose this option will still receive full medical and nursing care while in hospital.  The emphasis of care is often placed on maintaining a patient’s comfort.

 

While the development of CPR has been a great advance in providing an extended life to some patients, it is not always “as advertised on television”.  This medical procedure has a number of limitations and is frequently associated with complications.  People should have an understanding of the risks and benefits before making their decisions regarding this treatment. The choice to request or forgo CPR will not affect a patient’s other treatments in hospital but the decision needs to be discussed with a patient’s family members and physicians so that decisions are clear in the event that CPR is being considered.

 

 

Peter Aikman, MD, CCFP is a clinical fellow in the Care of the Elderly Program and has worked in a number of areas of the Southeastern Regional Geriatric Program.