Life Matters Media
Start the most difficult conversation American isn’t having- 
the conversation about our end of life preferences

CPR Versus DNR For The Elderly Patient

BY SUSAN M. MATHEWS, PH.D.

Most do not wish to think about a do-not-resuscitate order, whether for themselves or for a loved one.

However, this is not a decision that should wait until a crisis and hospital admission, especially as we age. An advance directive or conversation about resuscitation with a doctor, at the very least, are expressions of your wishes.

A DNR order is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing. Unless instructed otherwise, hospital staff and paramedics will attempt to revive any patient whose heart has stopped or who has stopped breathing. Your doctor will file a DNR order in your medical record; doctors and hospitals in every state accept them.

Popular TV shows do not capture the violent nature of CPR: chest compressions at least two inches deep and 100 times per minute. Sometimes, air is forced into the lungs. An electric shock is then sent to the heart in attempts to make it beat again. If successful, CPR can cause major trauma. Such trauma often includes fractures to the rib, sternum and spine. CPR sometimes results in injuries to the liver and spleen, damaged airways, internal bleeding, heart contusions and pulmonary complications.

According to Reuters Health citing a respected study, “when older hospitalized patients need revival by CPR, more than half are likely to die before they are discharged.” Patients who are successfully resuscitated may spend extra days or weeks in the hospital, but still not survive.

A total of 29 previous studies involving a total of 417,190 patients ages 70 and older were reviewed. These studies investigated the survival rates of patients undergoing in-hospital CPR. They found that about 40 percent of the patients had successful CPR, or “return of spontaneous circulation,” but more than half of those patients ultimately died in the hospital.

For patients ages 70 to 79, the rate of survival to discharge was about 19 percent. For older patients, outcomes were more grim. Among those ages 80 to 89, the rate was 15 percent. Less than 12 percent of patients 90 or older were eventually discharged.

“The chance of survival to hospital discharge for in-hospital CPR in older people is low to moderate and decreases with age,” the study said. And those who are discharged may be left with functional deficits.

In pulling together data that looks at functional deficits, the following chart outlines what post arrest/CPR neurological functioning might look like. The numbers do not offer a positive picture for patients interested in restoring health rather than prolonging death.

GRAPHLMM

“Even though the survival rates appear to be low in older people in general. … there could be certain elderly patients for whom CPR is a worthwhile intervention,” the authors write. The authors call for future research to determine which pre-existing factors lead to actual CPR benefit.

People can take some control over their wishes. Advance directives, particularly healthcare power of attorney documents, are critical roadmaps for families and medical professionals and should be in place well before a crisis. In fact, the latest acronym replacing DNR directs physicians to “Allow Natural Death” (AND). This does not mean that physicians are to stop treating illnesses a person needs help with, such as pneumonia, a heart attack, or a fractured bone. It means only that if the heart should stop: do not administer CPR and do not connect a ventilator.

I argue most people would opt for natural death. Doctors would. … and that’s worth another discussion and another column.

– Image courtesy Pixabay