The other day I was sitting outside a patient’s room waiting for the hospital employee to finish taking orders from the patient for meals for the following day.
The patient had to decide between chicken, beef and fish for lunch.
Once the orders were put into the computer, I stepped into the room to see the patient.

The patient was an 87 year old man with a widely metastatic cancer. His condition was terminal and no further treatment was offered by his oncologist. My plan was to discuss two issues with the patient -- pain control and resuscitation status. It’s good practice to decide if the patient wants to be resuscitated in the case of cardiac arrest. It is also a good idea to make this decision when things are relatively stable and the patient can take the time to think about it.

As I was talking to the patient, I couldn’t help but think that my conversation is no different than the one the patient had had earlier with the cafeteria employee. The options were different, but that’s about it;
“What do you want us to try for pain control?” was my question.
“We can try some vicodin or percocet. How about some morphine to get things under better control?” I asked.

The conversation regarding code(resuscitation) status went the same way:
“If your heart stops, do you want us to put you on a breathing machine and perform CPR?” The patient paused for a minute and as if picking items from a menu, stated that he is Ok with CPR but does not want to be on a machine. At that point I realized that the patient had very little understanding of what resuscitation meant and what the possible outcomes were. Performing CPR without providing adequate blood oxygenation will have limited effect, and vice versa, putting somebody on a breathing machine and not doing CPR will have no benefit in the case of a cardiac arrest.

It is our responsibility to help the patient to make the decision regarding life support by providing education and counseling on end of life issues. Sometimes, you, as a physician, will have to make that decision and communicate to the patient why CPR should not be performed. We do not offer patients surgery or a procedure if there is no benefit from doing it. Why should we offer CPR if the patient is unlikely to benefit from it and could, actually, develop complications related to CPR.

I strongly advice against resuscitation in the following circumstances:

When cardiac arrest will likely happen as a result of a severe and irreversible metabolic and physiologic change. At that point, performing CPR is futile since you cannot reverse the condition leading to it. The example would be a severe multiple organ failure and Acute Respiratory Distress Syndrome due to overwhelming sepsis. If patient’s lungs are so damaged that there is not adequate oxygen delivery and that causes the heart to stop, doing CPR is not going to bring the patient back. Of course, all the treatment options for the underlying condition should be exhausted first.

When overall life expectancy is poor due to an incurable disease or condition. The patient with a terminal, widely metastatic cancer should not spent his last days on a ventilator.

When CPR could actually cause more harm than good. Performing CPR on a 89 year old female with a severe osteoporosis will like lead to multiple rib fractures and potentially lung damage.

Having said that, it’s almost like a patient’s “right” to get CPR before death and refusing to perform it might have legal consequences. What we need is better education for the public on end of life issues and better protection for the physicians for refusing to provide futile care.

Have you ever done CPR? Not on a manikin but on a real person. It requires quite an effort. It also is a good exercise – it involves multiple muscle groups: arms, shoulders, back and even abs. I am surprised they don’t have it as a workout technique, something like TotalCPR or TurboCPR. The idea is to push against the chest wall elastic recoil and pump the blood out of the heart in an effort to preserve blood supply to the vitals organs. Providing rescue breaths used to be a part of CPR. That did not work very well in a community. Imagine that you have to wrap your lips over dead stranger’s mouth and blow air into his lungs. Not to mention that the person could have a communicable disease and a questionable oral hygiene. It has been changed recently – just chest compressions are good enough. Rescue breaths were not found to be ”effective” anyway and provider willingness to do it was a “concern”. No kidding!

Does CPR work? Yes it does. Like any good medicine it can save lives when used in the right circumstances. Imagine 50 or so year old gentlemen golfing with his friends and, suddenly, collapses. CPR initiated by his buddies. EMS arrives within minutes. The patient is being defibrillated by the Automated Defibrillator and transferred to the Hospital. He is taken to the Cath lab where cardiologist opens up one of his coronary arteries. The patient recovers completely and doesn’t even remember anything – like it never even happened. This is very good. This is how it is supposed to be.