ORIGINAL ARTICLE Cardiac and Pulmonary Resuscitation: Focusing on what matters.

Peter G Brindley MD FRCPC, Division of Critical Care Medicine, University of Alberta, Edmonton, Canada

ABSTRACT

RSUM

Cardiopulmonary resuscitation (CPR) has the remarkable ability to prevent otherwise inevitable death. Sadly, it can also significantly prolong the dying process, increase family duress and patient suffering, and squander scarce resources. Attempts to revive the failing heart and lungs date back hundreds of years. However, it was not until the 196O's that CPR was formalized.'' Fifty years on, it remains a topic of intense study, impassioned debate, divisive opinion, and legal consequence. It is, therefore, an important issue for all Healthcare Practitioners. While admission to a dedicated Palliative Care Unit typically means that CPR will typically no longer be an option, this is not the case for larger numbers of equally sick patients admitted to general hospital wards. In fact, CPR's "special status" is emphasized by the fact that it is the only medical intervention that requires explicit documentation not to be performed. Therefore, optimal communication cannot be overemphasized. Standardized Algorithms - as outlined by the guidelines for Advanced Cardiac Life Support (ACLS) - remain the recommended way to perform CPR. Guidelines are regularly updated, and widely taught.'^"'' As such, it is comparatively simple to proceed with CPR. It is far more important to decide upon its appropriateness. This review will therefore focus on prognostic factors in order to promote communication and advocacy. The intent is not to dictate who must (or must not) receive CPR. Instead, it is to provide baseline knowledge in order to encourage informed dialogue with patients and families. Only in this way can we deliver empathetic patientcentered care, even where the research is imperfect or the emotions extreme. The goal of CPR should be to extend life, not to prolong death.

La ranimation cardiorespiratoire (RCR) prsente la capacit remarquable d'empcher un dcs autrement invitable. Malheureusement, elle peut aussi prolonger l'agonie, augmenter les contraintes imposes la famille et les souffrances du patient et gaspiller des ressources prcieuses. Les efforts de ranimation des fonctions cardiorespiratoires remontent des centaines d'annes. Ce n'est cependant que durant les annes 1960 que la RCR a t structure'\ Cinquante ans plus tard, la RCR demeure un sujet d'intenses tudes, de dbats passionns, d'opinions divises et de consquences juridiques. Il s'agit donc d'un enjeu important pour les professionnels de la sant. Si l'admission dans une unit de soins palliatifs signifie habituellement que la RCR n'est plus une option, ce n'est pas le cas pour un grand nombre d'autres patients tout aussi gravement malades admis dans les units de soins rguliers. En fait, le statut particulier de la RCR est accentu par le fait qu'il s'agit de la seule intervention mdicale qui exige une documentation explicite pour ne pas tre excute. Par consquent, on ne peut trop insister sur l'importance d'une communication optimale. Les algorithmes normaliss noncs dans les directives sur les techniques spcialises de ranimation cardiorespiratoire restent la faon recommande de pratiquer la RCR. Les directives sont mises jour rgulirement et largement enseignes"^'. ce titre, si l'utilisation de la RCR est relativement simple, il est beaucoup plus important d'en dterminer le caractre appropri. Cet examen mettra par consquent l'accent sur les facteurs pronostiques, de faon favoriser la communication et la promotion. L'intention n'est pas de dicter qui doit (ou ne doit pas) bnficier de la RCR. Il s'agit plutt de fournir des connaissances de base afin de favoriser un dialogue clair avec les patients et les familles. Ce n'est que de cette faon que nous pourrons offrir des soins empathiques centrs sur le patient, mme dans les cas o les recherches sont imparfaites ou l'motivit extrme. Le but de la RCR doit tre de prolonger la vie, pas de prolonger l'agonie.

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Abbreviations (alphabetically): Advanced Cardiac Life Support (ACLS) Asystole (ASY) Cardiac Arrest (CA) Cardiopulmonary resuscitation (CPR) Coronary Care Unit (CCU) Do not resuscitate (DNR) In hospital (IH) Intensive Care Unit (ICU)

Operating rooms (ORs) Out ofHospital (OH) Pulseless electrical Activity (PEA) Restoration ofspontaneous circulation (ROSC). United States (U.S.) Un-witnessed cardiac Arrest (UW CA) Ventricularfibrillation(VF) Ventricular tachycardia (VT) Witnessed cardiac arrest (W CA)

BACKGROUND

Up to 750,000 CPR attempts occur annually in the United States (U.S.)' and the cost of unsuccesful efforts exceeds $1 billion U.S.' Of note, at least 70% of North Americans die in Hospital, and 25% of these occur in Intensive Care Units (ICUs).'" This means that, in North America, death has become an institutionalized experience and is intimately associated with technology. Furthermore, CPR is an expectation for anyone without explicit contrary documentation " and many physicians feel pressured to offer CPR regardless of patient factors. Equally, many are reluctant to stop CPR once they have started. However, reliable prognositicators are available to help determine whether to start and when to stop. As will be outlined, the greatest determinants of outcome are: whether the arrest was witnessed; the initial arrest type; and how long until restoration of spontaneous circulation (ROSC). CPR for > 20 mins without ROSC is associated with decreased survival." In fact, an arrest that is unwitnessed, that began as asystole, and had no ROSC after ten minutes of CPR has a predicted mortality of 100%." As such, physicians can estimate non-survival. Furthermore, overall, it is patient factors (i.e. "who" is resuscitated) that currently has a greater influence upon survival than resuscitation technique or technology (i.e. "how" they are resuscitated)
PATIENT FACTORS Initial Cardiac Rhythm

and 2/3rds of in-hospital arrests are currently ASY/PEA "(see below). This is a large part of why survival following cardiac arrest has not improved for the general hospital population despite 40 years of medical advances.""
Primary respiratory arrest (RA) versus primary cardiac arrest (CA) versus

In contrast to cardiac arrests, survival following primary RAs is significandy higher. Greater than 40% of respiratory arrest patients (i.e. requiring intubation but no need for chest compressions/defibrillation) survive to be discharged home." This compares with less than 15% discharged home following unwitnessed cardiac arrest.'" This difference is presumed to be because, by responding to RA, full cardiac collapse is avoided. As a result of the different survival rates, for some patients, it is appropriate to recommend pulmonary resuscitation alone (i.e. intubation and mechanical ventilation), but not full CPR (i.e. intubation plus chest compressions and defibrillation). This means patients still receive rapid attention, and ICU/CCU transfer, while at the same time avoiding potentially futile therapy. This also facilitates treatment of reversible illness and adequate attention to symptom control such as discomfort or dyspnea. This also prevents a do-not-resuscitate order (DNR) being misconstrued as "do-not-respond". This "middle-ground" may be reassuring to families who might otherwise misconstrue a DNR to mean patient neglect, or the false impression that the medical staff are simply "giving-up".
The Association Between Age, Co-Morbidities, and Survival

The order of "survivability" following cardiac arrest is consistent between studies."'" The likelihood of survival is greatest following ventricular fibrillation (VF) with decreasing survival following ventricular tachycardia (VT), followed by pulseless electrical activity (PEA) and is lowest for asystole (ASY). Strong co-linearity also exists between the arrest type and whether an arrest is witnessed, namely most ASY/PEAs are un-witnessed and most VF/VT are witnessed."' " Understandably, more in-hospital cardiac arrests (IH CA) are witnessed compared to out-of-hospital cardiac arrests (OH CA). However, what is concerning is that > 40% of all in-hospital arrests are still unwitnessed.

Several studies have reported an association between advanced age and poor survival following CPR, 14 but just as many have not. 11 This raises the adage familiar to clinicians of the contrast between "the good 80 year-old" and "the bad 80 year-old", and introduces the potential influence of co-morbidity upon survival. Many studies have found an association between being house-bound/functional dependant and significantly decreased survival following cardiac arrest.'^ Similarly, for

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elderly Nursing Home patients, survival is very poor with most studies reporting < 5% survival following CPR and <1% survival for unwitnessed Nursing Home cardiac arrestSi'''^''^^ However, almost 30% of NH patients receive CPR following un-witnessed arrests.^'' Even with on-site ACLS-trained physicians, and defibrillators, there was no significant survival improvement?''" Authors have therefore recommended not offering ACLS in this setting.^' Bedell et al. did fmd an association between decreased survival and renal failure, congestive heart failure, sepsis, hypotension, pneumonia and cancer." However, there is also disagreement in the literature regarding the influence of co-morbidities. For example, a Canadian multivariate analysis failed to find a significant association between survival and the presence of malignancy, sepsis, myocardial infarction, ptieumonia, renal failure or hypotension.'^ There is also a common assumption that those with cardiac illness who suffer a primary cardiac event are more likely to survive than those with non-cardiac illness (i.e. pneumonia) who then suffer a cardiac arrest.'^ Despite the apparent common sense that patients with single organ disease are likely to do better than those with multi-organ dysfunction, again the literature raises doubts. In a prospective study, Doig et al. found that survival was not significantly lower for those with four or more active medical problems versus three or less.'^ Definitive conclusions are likely complicated by differing study design and disease definition, but disappointingly there is insufficient evidence to definitively predict the outcome solely based upon pre-existing illness or advanced age. In contrast, consistent evidence exists linking the location of a cardiac arrest with survival. LOCATION OF CARDIAC ARREST Out of Hospital Cardiac Arrest (OH CA) OH CA has significantly lower survival compared to inhospital (IH) CA. This is likely because delay in CPR is a significant predictor of death. Therefore, if patients arrive in ASY despite OH CPR, many authors advocate ceasing CPR immediately.'-"^" Similarly, it has been recommended to withhold CPR,^' or not to exceed ten minutes," fot unwitnessed OH ASY. Furthermore, un-witnessed OH PEA with CPR greater than five minutes appears uniformly fatal.^' The Ontario Prehospital Advanced Life Support (OPALS) Study is the largest OH CA multi-centre study (17 cities, 18,000 cases) and found that survival to hospital discharge was roughly 5.0 %.' Interestingly, a Danish study reported an impressive 8.7% survival-to-discharge for OH arrests (and A&Vo survival to ten years).^' However, this pre-hospital system includes dispatched physicians who decided whether or not to perform CPR. Of note.

> 50% patients were not offered CPR. This selection bias reduces the study's generalizability at the same time as emphasizing the impottance of who is resuscitated upon survival.
In-Hospital (IH)

Survival to discharge following IH CPR for the general hospital population (and excluding those admitted to ICU/CCU) is typically <15%."'' Canadian data showed that, despite 40 years of medical advances, survival following IH CPR has not significantly improved, with 13.4% survival to hospital discharge." Of note, however, even this may represent a "best-case scenario", as the hospital studied were large tertiary-care urban hospitals that possessed 24hr "code teams", and Intensive Care (ICU) and Coronary Care Unit (CCU) back-up. This is in stark contrast to the lesser resources of rural hospitals. However, for the survivors, neurological recovery is often acceptable with > 50% of both adult and pdiatrie survivors maintain satisfactory cerebral performance."'^^ Survival to discharge following CA in ICU/CCU is as high as 30%.""* This nearly two-fold survival improvement when compared to general hospital inpatients is believed to be because arrests are witnessed and resuscitation begins almost immediately." As such, many hospitals wish to increase the number of monitored beds. Many hospitals are also focusing on ensuring rapid response with the hope of early identification and stabilization of patients in order to prevent full cardiovascular collapse. Regardless, this data emphasizes the importance of early response and also whether an arrest is witnessed.
Witnessed Arrests (WA) versus Unwitnessed Cardiac Arrests (UWA)

As stated above, survival is significantly higher following a WA, as compared to a UWA." To put this into stark contrast, in the above mentioned Canadian study when WA and UWA were combined approximately l-in-3 had R o s e , l-in-7 survived to hospital discharge, and 1-in-lO returned to independent living. This is in contrast to the 45% of arrests that were unwitnessed where only one-fifth had R o s e and where nobody survived to discharge. In contrast for the 55% of arrests that were witnessed approximately l-in-2 still achieved ROSC, with l-in-3 survival to 24 hrs; l-in-4 survival to discharge, and l-in-5 were able to return home." OTHER ISSUES Surgery for patients with pre-existing DNRs Many physicians are unsure what to do when the patient with a DNR order requires surgery. This is relevant as up to 15% of patients with pre-existing DNR orders currently

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receive operations." Reasons include relief of obstruction/pain; feeding tubes; tracheostomies etc. Most hospitals, appropriately, suspend DNR orders for the perioperative period. Reasons include because routine perioperative management usually requires cardiopulmonary support (i.e intubation for surgery), because routine recovery from the perioperative insult may require an ICU stay; and because operating rooms are inadequate for family visitation and bereavment if death occurs. Obviously issues remain as to what constitutes an appropriate peri-operative period such that the DNR may be re-instated. However, for all of these reasons, preemptive on ongoing communication is required in order for the patients wishes to be respected and for the OR staff to feel comfortable to proceed.
COMMUNICATION

times the actual survival rate. However it may represent the expectation of the lay public, at the same time that television may minimize the true consequences of attempted resuscitation. Regardless, it means that a useful starting point is to ask about patient's and families' assumptions. Equally, many physicians may be overly pessimistic regarding outcome following CPR. Therefore, it is our hope that this manuscript provides sufficient objective information to stimulate meaningful discussion. Overall, communication is central to Medical Care, and to patient and family satisfaction." It appears that much work remains to be done.
CONCLUSION

Therapeutic efforts should continue to improve outcome following CA.^^" However, the inevitability of eventual death means communication will always be paramount. Unfortunately, many physicians are reluctant to address resuscitation wishes. Even more concerning is that educational initiatives have not significantly improved this.^"^ There is also poor agreement between the beliefs of doctors, families, and patients, and inadequate communication is a frequent cause of conflict.^' In a novel review of cardiac arrests on television. Diem et al. found survival to be over 60%.'' This is two to four

Only three factors have been consistently associated with increased survival witnessed arrest (as c/t to un-witnessed cardiac arrest); VF/VT as initial cardiac rhythm (as c/t ASY/PEA); and restoring spontaneous circulation within 20 mins (i.e. not offering prolonged CPR). Laudable efforts to increase survival will continue. However, this mandates ongoing debate about when this offers a chance for "better life" and when it threatens a "worse death". Technological advances must not supplant open communication, nor can they replace individualized decision-making. In short, "technology" must not replace "humanity". Few specialties understand this better than Internal Medicine. As such, its voice is needed now and in the future.

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23. Tresch DD. Nearing JM, Duthie EH, et al. Outcomes of cardiopulmonary resuscitation in nursing homes: can we predict who will benefit? Am J Med 1993;95:I23-30. 24. Kane RS. Considering CPR policy. J Am Geriatr Soc 2000;48(5). 25. Gordon M, Cheung M. Poor outcome of on-site CPR in a multi-level geriatric facility. J Am Geriatr Soc 1993;41:163-6. 26. Bailey ED, Wydro GC, Cone DC. Termination of resuscitation in the pre-hospital setting for adult patients suffering nontraumatic cardiac arrest. National Association of EMS Physicians (NAEMSP) Standards and Clinical Practice Committee. Prehosp Emerg Care 2000;4:190-5. 27. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Circulation 2000;102 Suppl 8:1142-57. 28. Vayrynen T, Kuisma M, Mtt T, Boyd J. Medical futility in asystolic out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 2008;52(l):81-7. 29. Vayrynen T, Kuisma M, Mtt T, Boyd J. Who survives from out-of-hospital pulseless electrical activity? Resuscitation 2008;76(2):207-13. 30. Stiell IG, Wells GH, Field BF, Spaite DW, et al. Advanced cardiac life support in out-of-hospital cardiac arrest. New Engl J Med 2004;351:647-56. 31. Holler NG, Mantoni T, Neilsen SL, Lippert F, Rasmusen LS. Long term survival after out-of-hospital cardiac arrest. Resuscitation 2007:75:23-8

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Correspondence to: Dr. Peter Brindley, Associate Professor and Residency Program Director, Division of Critical Care Medicine, Unit 3C4, Walter C. Mackenzie Centre University of Alberta Hospital, 8440-112 Street, Edmonton, Alberta T6G 2B7, Canada Tel: (780) 407-8822 Fax: (780) 407-6018 Email: peterbrindley@cha.ab.ca

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