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.  

CPR outcomes

Long time between posts.  This article is heading in a direction that I like which is making outcomes of CPR transparent.  More to follow.

Another goals of care sheet

I am always looking to find a perfect form that would help me understand and help patients clarify their goals of care.  There are so many different values to discuss such as

Longevity goals

Quality of life goals  (both ideal and minimal)

Function goals (both ideal and minimal)

Comfort goals

Risk tolerance

Pain tolerance

Definition/purpose of suffering

Emotional issues

Cultural issues

Ideal place of death

Worries of abandonment vs desire for community

Views on technology (fear vs embrace)

Role with family (involved, independent)

Role with doctor (involved, independent)

          Model of decision making (informed consent vs paternalistic vs collaborative)

Concerns of being a burden to others (physically, emotionally)

Milestones to live for (an upcoming wedding/graduation/birth)

Dignity issues (care received, relationships, function)

There are a ton of medical decisions and implications that need to be made as well.   

Current health status

Projected health status/anticipated quality of life

Burden of medical interventions (both pain and risk)

In addition to a million individual decisions (Dialysis, ICU care, ER care, invasive testing, CPR etc)

I've made sheets of my own, but one that I am finding very very interesting is "The Conversation project."  I'm thinking of abandoning my own forms and using this one paired with a POLST form.  I'll let y'all know how it works out!

Geriatricians are the GPS of the health care system

It is sometimes difficult to explain how geriatricians are different than other physicians.  Yes we deal with diseases and syndromes like Dementia, weight loss, transitions of care that other physicians don't like to manage.  But there is something more and I always had a hard time succinctly explaining it.  I decided to use the idea of a GPS to explain how qualitatively Geriatricians are different.

First, most physicians have very disease/organ focused view of health.  The right way to treat a heart that is failing is determined by studies and guidelines.  But for geriatricians there are a number of things we consider in addition that are very patient oriented.  On the continuum of therapeutic and palliative goals, what does the patient want us to accomplish?  How is health, quality of life, suffering and risk defined?  These are questions that patients can only answer for themselves.  Geriatricians call this goals of care.  In addition to efficacy questions that most physicians ask, geriatricians take into account life expectancy (will patients live long enough to see a benefit), what is the potential harm (risk) and is that tolerable to a patient (pain tolerance), what is the real likelihood of a treatment creating benefit (is it worth it) and is a treatment worth the pain (combining risk and benefit).  By thinking of goals first and using them as an anchor (or destination in my GPS analogy), fitting evidence to patient oriented goals and limits, interventions become more rational.

Here are some big picture stats:
1/3 of severely ill Medicare patients with palliative goals feel that their care is too aggressive.
13% of people with severe dementia with a feeding tube got a feeding tube with no discussion between the doctor and family about whether it was even wanted.
Less than 50% of severely ill patients have an advance directive in their medical record, only 1 in 8 receive input from their physician and the vast majority of physicians are unaware of the patient's advance directive.
88% of dialysis patients never knew that home dialysis is an option
Most cardiologists that recommend ICD's never discuss the risks with the patient but feel adhering to guidelines matters more.
Not only do patients get more aggressive care than they want, sometimes patients request more aggressive care than doctors feel is in the patient's best interest.  And the opposite happens as well-older patients are sometimes treated as if they are already dying and desired, effective, tolerable care gets denied due to age alone.
These stats could go on and on.

I will add four examples from my own patients.  After doing what I do, I kinda assume that everyone thinks like me (why wouldn't they?!).
The first patient was a 90+ year old patient with severe dementia, bed bound, contracted, oriented to self and family but not place or time.  She was at home surrounded by family.  She was able to enjoy her family, eat and was pain free.  She developed a sacral wound that then walled off leaving a cavity underneath healed skin.  She had no fever or signs of systemic illness (normal white count).  She was admitted to my inpatient unit.  We consulted surgery who recommended debridement under general anesthesia as this likely went to bone.  We met with the family, discussed goals, risks and time to benefit.  We discussed her current quality of life, her goal of comfort and tolerance of the risk.  After getting to know the family we decided to leave the wound alone unless she became systemically ill and even then would still probably leave it alone.  We discharged her home with just local wound care.  I received a phone call from her quite irate family doctor who after about a half hour of discussion basically said I was not even trying to help the patient, committing her to death.  When I informed him of the extensive family meetings and content, he said families don't know what is right and that physicians need to tell the families what to do.  It dawned on me that this physician would rather have his patient die in the operating room or after after a painful post op wound care course that would involve institutionalization in a nursing home to get more daily advance wound care treatment than to simply focus on comfort, quality of life and calling it a day.  In his mind, real physicians try to help their patients live as long as possible even if it results in catastrophic failure and fails to meet any goals.

The second patient was very similar.  90+ years old with severe dementia in a nursing home.  Pt had progressive kidney disease to the point where dialysis was the "right" treatment for her kidney function.  However she was asymptomatic, could even stand up and dance during music recreation time and had her friends she ate with 3 times a day.  The renal doctor decided to call the son to initiate dialysis over my objections saying that without dialysis she would die.  Despite my objections that dialysis could kill her sooner, make her feel worse, make her spend less time enjoying her life even if she lived longer, the nephrologist convinced the son to put in a dialysis catheter.  One week later, the patient got septic and died from a catheter infection.  Again, "at least she tried."

The third patient was an office patient, also in his 90's.  He was diagnosed with severe heart failure and was hospitalized 3-4 times in 6 months.  He was also diagnosed with metastatic melanoma.  He had a fall and minor hip fracture not requiring surgery.  During one of the hospitalizations, his cardiologist walked into his room and recommended an implantable defibrillator saying that "it would help" him.  No further discussion.  So the next day, he had a $50,000, 10 year device placed.  When I saw him in the office I asked him what he hoped it would accomplish.  He had no idea.  I had a very frank discussion that he was going to die in the next year either from congestion in his lungs, metastatic cancer, continued frailty/immobility or an arrhythmia.  The purpose of the ICD would be to not allow him to die of the most peaceful way (the arrhythmia).  He said that he didn't want it, I emailed the cardiologist who agreed to turn it off and it became a $50,000 oops.  (I got paid $100 tops for the discussion).  The unfortunate thing was although he signed on to hospice, the cardiologist stopped seeing him and didn't turn off the defibrillator.  Fortunately, 6 months later he did die without the device ever firing.  But at least the cardiologist "tried."

The last patient was a 90+ year old bed bound patient with severe dementia at my nursing home.  She was unable to talk, did not recognize herself.  She had end stage renal disease.  She had severe daily arthritis pain and sedation from pain medications.  She had a heel wound as well.  She went to the hospital for fever or shortness of breath (I don't remember), coded (vfib arrest), was shocked back into sinus rhythm but had to be intubated and was sent to the ICU.  So now my 90+ year old patient has end stage dementia, end stage renal disease, severe daily arthritis, respiratory failure on a vent, s/p cardiac arrest and has a heel wound.  A surgeon came over and recommended a below the knee amputation under general anesthesia.  Infectious disease, vascular, the critical care doctor and the family agreed.  Despite my phone calls over 2 days, the surgery went on as scheduled.  The next day after the amputation she died on a ventilator in the ICU.   At no point did anyone else consider hitting the breaks.  At least the vascular surgeon "tried."

So what's my point?  Without an anchoring in goals, the amazing things we can do with medicine is like a fast exotic car with no brake pedal, steering wheel or destination in mind.  We do a lot, sometimes it is too much, too little and often ineffective for what matters to patients.

I leave you with my attempt at a cartoon.
Health care with geriatricians...

Health care without geriatricians...

Geriatrics isn't dead

As a relatively new geriatrician (finished my fellowship in 2009), I often hear about how geriatrics is dying as a field from those within academia and who have a larger view of geriatrics as a field (see this link for an example).  While geriatrics (100 US med grads, 275 total per year) may never be in the same ballpark as Internal Medicine (8800 new grads a year), Family Medicine (3300), Pediatrics (2900), Gen Surgery (2300), ER (1700) or Obstetrics (1300) in terms of volume, the field may persist quite healthily as a smaller specialty such as Plastic Surgery (116), Vascular Surgery (123), Thoracic Surgery (90), Allergy Immunology (131) or most pediatric subspecialties (ER, GI, Endo, Cardiology, Rheumatology, Nephrology etc).  After seeing numbers that JAMA publishes yearly I am more optimistic that geriatrics will at least survive as a specialty.  Ideally we would be the other end equivalent of pediatrics but that's not going to happen.

More care ≠ better care

I don't even need to blog with articles like this showing up on the internet!

Bring up hospice is like proposing to one's girlfriend

1.  It shouldn't be a surprise
2.  You should have some idea of the answer before you ask the questions
3.  It is not how you start the conversation.
4.  Don't consult social work, ask yourself!

It's interesting to me how intimidating it is for doctors/residents/med students to bring up hospice (for a variety of reasons) and for patients/families to have it brought up or to bring it up.  So to make thing simpler, I've come up with this analogy that I think applies for at least these 4 reasons.