Sunday, October 13, 2013

CPR outcomes-how do I decide my code status?

So I finally got around to my literature review on CPR outcomes in older adults.  Cardiopulmonary resuscitation status (or code status) is asked at every hospital admission as required by law.  But how does one make a decision regarding whether or not CPR is right for them?  Understanding CPR outcomes is a starting point.  Having an accurate understanding is the anchor for deciding fit between values and the procedure (in this case CPR).

In a nutshell:
1.  CPR achieves

  • Nothing for 50% of patients in the hospital
  • For around 35%, the patient has a prolonged death in the hospital
  • For around 15% the patient survives to leave the hospital.
  • About 8% leave the hospital about the same as when they came into the hospital.

            For those with end stage anything disease (end stage heart failure, COPD, renal disease on dialysis, severe dementia, metastatic cancer), survival rate are easily less than half of that (so 7.5% survive and 4% survive to be about the same).  Because of the way these studies are done, the number could be cut in half again.

So for sick patients, older patients, the best number to use would likely be

  • About 1-3% with severe disease will leave the hospital about the same as when they came in.

2.  There are risks.
  • Trauma.  1/3 break ribs for example.  More as you get past 70 years old.  CPR can hurt.
  • Prolonged death that is more painful.  Some people, instead of suddenly dying peacefully in their sleep from their heart stopping, will die from not being able to breath on a mechanical ventilator.  (about 35% of those who get CPR).  
  • Living more dependently.  About half of survivors who were at home need to go to a Nursing home after CPR.  
  • If a person is full code, then by definition, CPR will be the last thing they experience on this earth.  

So what to make of all this?  Everything is in the eye of the beholder.  For some people, having a 2-3% chance of living longer (even if it is just a couple of months) is totally worth it.  For others, it seems like a vanishingly small percentage and a complete waste.  There is no right answer.  For others, the trauma, risk of prolonged death, or the absence of a peaceful death is something worth avoiding at any cost.  For others, it is no big deal.  

So this is how I think about it:
CPR is good for you if ALL of the following are true:
  1. Longevity is still an important goal
  2. Dying peacefully is not a goal
  3. Avoiding a prolonged death is not a goal
  4. Comfort is not an important goal
  5. You have a high tolerance for trauma
  6. You're okay with living very dependently in things like bathing, dressing, toileting and feeding.
  7. You are a gambler/risk taker.  Although you're hoping that after CPR you'll be the same, you won't regret your decision if you end up with a feeding tube for example because you're happy you went for it.  
If one of the above is not true, well then you have a decision to make right?  Is the tiny chance to living longer worth the pain?  No one wants pain but is the chance worth it?  Not to be too glib, but to quote Clint Eastwood, "you've got to ask yourself one question: 'Do I feel lucky?' Well, do ya, punk?"  There's a certain amount of gambling optimism to be full code.  Or absolute fear of dying where you're willing to take risks.  The chances of coming through is a little better than playing the pick 3 lotto.  So if you're really ticked off every time you don't win after playing the pick 3 lotto, well, then, you'd probably not be too happy after you get CPR. 

Onwards:  CPR is not a good choice for you if any one of the following is really important for you
  1. Longevity is no longer a goal at all
  2. Dying peacefully is very important (i.e. without painful procedures, with family present)
  3. Comfort is a non negotiable goal
  4. Avoiding a prolonged death is vitally important
  5. Living very impaired is to be avoided if possible 
  6. You have no desire to put up with any more pain
  7. You're not a gambler.  
Anyway, it is up to the patient and physician to work together to figure out the fit between a patient's goals/values/limits and what CPR can realistically achieve for that patient.  It is much more complicated than "I'd like to live longer so let's go for it."  CPR is likely to make a person worse (all good intentions aside) and I would not want a person to be surprised or regret it.  

No comments: