Resuscitation Preferences

Discussing resuscitation preferences is important for patients with advanced illness and advanced frailty who are appropriate for MOLST. A thoughtful MOLST discussion begins with preparation for the discussion as outlined in step 1 of the 8-Step MOLST Protocol. Reviewing resuscitation and other life-sustaining treatment preferences is Step 7.

Cardiopulmonary Resuscitation

Cardiopulmonary resuscitation (CPR) is intended to prevent sudden, unexpected death.  Unless there is a medical order to withhold CPR, all attempts to prolong life are provided in an emergency when a person experiences cardiac and/or pulmonary arrest (i.e. the heart stops or when breathing stops).

CPR involves artificial breathing and forceful pressure on the chest to try to restart the heart. It usually involves electric shock (defibrillation) and a plastic tube down the throat into the windpipe to assist breathing (intubation). It means that all medical treatments will be done to prolong life when the heart stops or breathing stops, including being placed on a breathing machine (ventilator) and being transferred to the hospital.

A medical order to withhold CPR is called a “DNR Order” and means “Do Not Attempt Resuscitation” and “Allow Natural Death.”  It does NOT mean Do Not Intubate (DNI) if a patient experiences respiratory insufficiency. It does NOT mean Do Not Hospitalize (DNH) and does NOT mean Do Not Treat.

CPR is not indicated in cases of terminal, irreversible illness where death is expected, or in certain medical situations where CPR is deemed ineffective. For many people resuscitation is unwanted, unneeded and impossible. Depending on the patient’s medical condition and preferences, CPR may be inappropriate, futile and undignified.

Conversations Based on Evidence

The success rate of hospitalized patients with advanced illness, multiple comorbidities and moderate frailty to terminal illness should be considered when having thoughtful MOLST discussions and making resuscitation and other life-sustaining treatment decisions in this patient group.

Survival Rates

Chronic Illness

• A 2014 study examined inpatient Medicare data from 1994 through 2005 and identified 358,682 CPR recipients. Medicare beneficiaries aged ≥ 67 years were grouped by severity of six chronic diseases—COPD, congestive heart failure (CHF), chronic kidney disease (CKD), malignancy, diabetes, and cirrhosis—and investigated survival to discharge, discharge destination, rehospitalizations, and long-term survival.
• Older adults who were CPR recipients with any of the six underlying chronic diseases investigated generally had much worse outcomes than CPR recipients without chronic disease. Among discharge survivors, most were discharged home less often, experienced more hospital readmissions, and had worse long-term survival.
• These findings may substantially affect decisions about CPR in patients with chronic illness.

Advanced Illness and Multiple Comorbidities

• The same 2014 study of inpatient Medicare data compared outcomes among recipients with chronic disease and advanced illness.
• Although 7.2% of CPR recipients without chronic disease were discharged home and survived at least 6 months without readmission, ≤ 2.0% of recipients with advanced COPD, CHF, malignancy, and cirrhosis (P < .001 for all) met these criteria.”

Advanced Frailty

Frailty is associated with adverse outcomes from in-hospital cardiopulmonary resuscitation.

• A 2019 study of patients Analyzed 179 in-hospital cardiac arrest cases and found that survival to hospital discharge was associated with frailty.
• Patients with moderate or greater frailty, as determined by the Clinical Frailty Score (CFS Score), with a CFS score ≥6 that signified moderate or greater frailty, are unlikely to survive to hospital discharge even if Return of Spontaneous Circulation (ROSC) occurs following CPR.
• ROSC was achieved in 56.1% of patients with a CFS score of 1–5 and 32.1% with scores 6–9 (p < 0.001).
• Survival to hospital discharge was associated with frailty, occurring in 31.7% of patients very fit to mildly frail, but only in 1.8% of patients moderately frail to terminally ill.
• The success rate of hospitalized patients with moderate frailty to terminal illness is <2% and should be considered when making resuscitation status and MOLST decisions in this patient group.

TV Does Not Reflect Reality

• Public perceptions of cardiopulmonary resuscitation (CPR) can be influenced by the media.
• A 1996 study found that the rates of survival following CPR were far higher in popular TV shows than actual rates.
• In recent years, major strides toward enhanced education and communication around life sustaining interventions have been made.
• A 2015 study aimed to reassess the accuracy of CPR portrayed by popular medical TV shows, as well as whether these shows depicted advance care planning discussions of care preferences and referenced advance directives.
• In the 2015 study:
  • CPR was depicted 46 times in the 91 episodes, with a survival rate of 69.6%.
  • Among those immediately surviving following CPR, the majority (71.9%) survived to hospital discharge and 15.6% died before discharge.
  • Advance directive discussions only occurred for two patients, and preferences regarding code status (8.7%), intubation (6.5%) and feeding (4.3%) rarely occurred.

Conversations Based on Evidence

Statistics to keep in mind when having discussions about CPR:

• Survival rate of CPR on television shows: 69.6%
• Hospitalized patients with advanced chronic illness who are appropriate for MOLST: <2%
• Hospitalized patients with advanced frailty who are appropriate for MOLST: <2%

References

• Adams, D., & Snedden, D. (2006, Jul). How misconceptions among elderly patients regarding survival outcomes of inpatient cardiopulmonary resuscitation affect do-not-resuscitate orders. Journal of American Osteopathic Association, 106(7), 402-4. Retrieved Mar 26, 2020
• Diem, S. J., Lantos, J. D., & Tulsky, J. A. (1996, Jun 13). Cardiopulmonary Resuscitation on Television- Miracles and Misinformation. The New England Journal of Medicine, 334, 1578-1582. doi:10.1056/NEJM199606133342406
• Pape, M., Rajan, S., Moller Hansen, S., Mortensen, R. N., Riddersholm, S., Folke, F., . . . Gerds, T. A. (2018, Apr). Survival after out-of-hospital cardiac arrest in nursing homes – A nationwide study. Resuscitation, 125, 90-98. doi: 10.1016/j.resuscitation.2018.02.004
• Portanova, J., Irvine, K., Yi, J., & Enguidanos, S. (2015, Nov). It Isn’t Like This on TV: Revisiting CPR Survival Rates Depicted on Popular TV Shows. Resuscitation, 96, 148-150. doi:https: 10.1016/j.resuscitation.2015.08.002
• Sasson, C., Rogers, M. A., Dahl, J., & Kellerman, A. L. (2009). Predictors of Survival From Out-of-Hospital Cardiac Arrest. Circulation: Cardiovascular Quality and Outcomes, 3(1), 63-81. doi: 10.1161/CIRCOUTCOMES.109.889576
• Segal, N., di Pompeo, C., Escutnaire, J., Wiel, E., Dumont, C., Castra, L., . . . Hubert, H. (2018, Mar). Evolution of Survival in Cardiac Arrest with Age in Elderly Patients: Is Resuscitation a Dead End? The Journal of Emergency Medicine, 54(3), 295-301. doi: 10.1016/j.jemermed.2017.11.018
• Stapleton, R., Ehlenbach, W., Deyo, R., and Curtis, J.R. (2014, Nov.) Long-term Outcomes After In-Hospital CPR in Older Adults With Chronic Illness. Chest, 146(5): 1214–1225. doi: 10.1378/chest.13-2110
• Tresch, D. D., Neahring, J. M., Duthie, E. H., Mark, D. H., Kartes, S. K., & Aufderheide, T. P. (1993). Outcomes of cardiopulmonary resuscitation in nursing homes: Can we predict who will benefit? The American Journal of Medicine, 95(2), 123-130. doi: 10.1016/0002-9343(93)90252-K
• Wharton, C., King, E., & MacDuff, A. (2019). Frailty is Associated with Adverse Outcome from In-Hospital Cardiopulmonary Resuscitation. Resuscitation, 143, 208-211. doi: 10.1016/j.resuscitation.2019.07.021