The Inconvenient Truth About CPR - There Are Pros and Cons
By Don Drake, Connelly Law Offices, Ltd.
At a recent presentation about Advance Directives, given by professional fiduciary and certified elder law attorney RJ Connelly III to a large group of seniors, it became clear that there is still a lot of confusion surrounding the use of the MOLST/POLST form, especially around the use of cardiopulmonary resuscitation (CPR). Many seniors had differing opinions on the purpose and use of this form for those living independently or in assisted living and long-term care facilities. Attorney Connelly stressed the importance of discussing end-of-life options, even though it can be a complex topic to approach, especially with America's aging population.
In a conversation about the POLST/MOLST form, seniors expressed their worries, and Attorney Connelly attempted to alleviate them by citing the National POLST Organization. Despite this, they remained unconvinced, particularly regarding CPR as a resuscitative measure. Most seniors believed that CPR should be administered to everyone, regardless of their condition, since many believed "it always succeeds". However, Attorney Connelly pointed out that CPR is not a foolproof solution and can harm elderly patients with terminal illnesses or severe heart damage. It may also cause additional internal injuries and fractures, which must be considered before deciding to undergo CPR.
Many seniors at the event were unaware of the advantages and disadvantages of CPR on older individuals. As a result of this gathering, we would like to reiterate a previously published blog post.
A few months back, an article was written by Dr. Liz O'Riordan, who specializes in oncoplastic breast surgery (a combination of traditional breast cancer surgery and plastic surgery techniques), for The Daily Mail. The article discusses the significance of advance directives and CPR's harsh reality. We would like to share this article with you. But first, let's learn a little about the doctor.
A Doctor and a Patient
Dr. O'Riordan knows all too well what she writes, being diagnosed with Stage 3 breast cancer in 2015 at forty and having it return just three years later and again successfully treated. Because of what she experienced as a doctor and a patient, she started an award-winning blog about her experiences, leading to her lecturing internationally about improving the quality of patient care.
Even after retiring from her medical practice, she still works part-time as a public health consultant. Her job involves reviewing the notes of patients who have passed away in the hospital, with the aim of identifying ways to enhance the care of dying patients. Additionally, she has created a WhatsApp group for doctors who have cancer, where they can share their individual experiences of being both a patient and a medical professional.
Attorney Connelly stated that due to her past experiences and expertise in the field, Dr. O'Riordan possesses a valuable outlook on the topic of end-of-life measures that should be given careful consideration. The purpose of the article is to shed light on the existence of the MOLST form. Here is the article by Dr. O'Riordan as published in The Daily Mail.
Heroic Measures Are for TV Shows
The first time I saw CPR being performed was on TV. I was in my teens – it was probably the American medical drama ER. Maybe it was Casualty. There would always be a frantic scene of a medic pumping away at a patient whose heart had stopped. Someone would rush in with defibrillator paddles. Someone else would yell 'CLEAR!' For a moment, all hope seemed lost and then the body would jolt back to life. Relief all around. The patient was up and talking, or perhaps even heading home, before the credits rolled. It was gripping, dramatic and glamorous.
Years later, as a fledgling doctor working on a crash team on hospital wards, I got to see it and do it for real – and it couldn't have been more different. CPR, or cardiopulmonary resuscitation as it's formally known, is brutal and undignified. It's given when the heart stops – so in effect the patient has died – in the hope that it will bring them back to life. But it almost never works, because it is generally carried out on patients who are the sickest and the frailest in the hospital.
Their clothes are pulled off so the crash team can get paddles on their chest, and there are medical staff everywhere. Some are feeling for a pulse, others are cleaning up blood and vomit. It is noisy. Someone is shouting out the number of chest compressions, doctors grunt as they press down. Rib fractures are incredibly common because of the force needed to start the heart – you can hear the bones break. If a patient's heart does start beating, they may be left with bruised or bleeding lungs. And damage to the brain and kidneys is not uncommon – because of the time spent without the heart pumping blood around the body.
CPR if Successful, Has Drawbacks
In eighty per cent of cases where CPR is successful, the patient never leaves hospital.
Two-thirds of them die within a few days. About two per cent are left in a long-term vegetative state – neither dead, nor truly alive.
The one time I did bring someone back, when I was working in [the Emergency Room], the man was in intensive care for two weeks. Then we realized he would never recover and had to turn off the ventilator. It was horrible for his family. Later, as a surgeon specializing in breast cancer, I had to discuss all this with patients. Whether we want to be resuscitated if our heart stops is a routine question doctors ask when they admit someone.
It can feel alarming. But it's important, if someone is particularly ill and not going to get better – with late-stage cancer, for instance – that they understand if their heart stops, CPR really will just delay the inevitable, at best.
More recently, I've had to face up to my own potential death, after being diagnosed with breast cancer twice – for the first time in 2015, when I was forty, and then again three years later. Thankfully, my treatment was a success. But the experience spurred me into making some decisions about how I'd like my life to end. It wasn't easy.
No woman wants to talk to her husband about how she might die before him. But it's vital we make our wishes known. In particular, I have made it clear that if I reach the end of my life – if my cancer comes back and my heart stops beating – then I don't want CPR.
Making My Choices
Of course, if I had a sudden heart attack out in the street tomorrow – while I'm fit and healthy – and a defibrillator was close by, then I would absolutely want someone to try it on me. But that's because I'd actually have a chance of recovering. The chances are, if I'm very unwell – whether I'm being cared for at home or in hospital – that even if CPR did restart my heart, I'd be in a worse state. And that's not how I want to die.
I'd like to be in bed surrounded by my family, not a team of doctors trying to bring me back to life. It doesn't mean I won't receive treatment. Far from it. But I just want medical care to make me as comfortable as possible at the end. Of course, there will be those with long-term health conditions who think the opposite. They might say, 'I want to be given a chance no matter what.' But that needs to be a decision that's made after considering the facts. And I'm all for that. No one can tell you what to choose.
For a person in full health, whose heart stops unexpectedly, CPR, if given within minutes, offers a ten to twenty percent chance of survival. There is still a significant risk of long-term damage, but the benefits far outweigh this. If a person has serious long-term health problems, and their heart stops unexpectedly, CPR has a smaller chance of success – the heart may restart, but the body is unlikely to recover. And if a person has a terminal illness, if they are dying, and if there's significant damage to the lungs, liver, and kidneys, CPR is futile, in my opinion.
Restarting the heart cannot repair the damage already done by the illness. Of course, like anyone, I was horrified to read of 'Do not resuscitate' orders being written on medical files of elderly people in care homes during the pandemic, without prior discussion. And I have heard of cases where doctors have explained things badly and have caused distress. Not all doctors have excellent bedside manners.
Use a MOLST and Living Will
In the hospital, if you are too sick to tell someone what you want, a senior doctor may decide not to administer CPR if it would do more harm than good – and loved ones can find this difficult without careful conversations beforehand. If you have a relative who's been admitted, and is very [sick], it's worth raising the subject. If the wish is to have CPR doctors will try to honor that.
And if, having thought about this, you think that you might not want to be resuscitated in some circumstances, then there are steps you can take to make sure people know.
If you are already under the care of a medical team, discuss your wishes with them.
There is a form your doctor will fill in to keep in your medical notes called [in the United States, the POLST/MOLST form]. This doesn't mean you won't get treatment – but if your heart stops, there will be no attempt to restart it.
If you want to make sure your relatives know your wishes, you can create a living will that lets you refuse medical treatment. It can be altered. It's only used if you're unable to communicate. It's another way to ensure people close to you know your wishes. I made a living will. It wasn't pleasant. But I'm content to know I will be spared CPR – and have the death I want.
A Final Word
Dr. O'Riordan gives us a lot to think about regarding the use of CPR in older adults with pre-existing chronic and life-threatening illnesses or conditions. As we close out this blog, here are two facts to remember about the use and success of CPR:
Research shows that only ten to twenty percent of all people who get CPR will survive and recover enough to leave the hospital.
For the chronically ill, only five percent of those who CPR resuscitate live long enough to leave the hospital. In those cases, most have difficulty recovering from the damage caused by CPR.
"Dr. O'Riordan's article points out some hard truths about CPR in seniors and those who are frail or have a terminal illness," said Attorney Connelly. "Research shows that besides the physical trauma that occurs, patients who receive CPR also have to deal with serious long-term consequences like possible brain damage from oxygen deprivation, which is much more of an issue for an older individual."
"The reality is that older bodies are physically weaker and therefore less likely to recover from the CPR procedure itself," continued Attorney Connelly. "And as the doctor pointed out, the existing health conditions that caused the heart to fail make it even less likely that they'll recover or have a decent quality of life afterward. This bolsters the argument that CPR on seniors can lead to an unnecessarily prolonged and painful death. As hard as this is to discuss, these are things that individuals and families must consider when a loved one has a serious chronic or life-threatening illness, and as Dr. O'Riordan said, having the death they want."
Local POST/MOLST information: Rhode Island Massachusetts Connecticut
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