NO CPR, Please!

“Do you want CPR--cardiopulmonary resuscitation?”
 
That was the last of a series of questions asked by the admitting doctor after my transfer from the Emergency Room to a regular patient room in 5 East University Hospital. I had been taken to ER after fainting in church.
 
The question surprised me. I didn’t regard myself as a candidate for the long trip to the great beyond. The doctor reassured me the question wasn’t meant to say anything about the condition of my health. Rather it was to find out what I would want to happen in case my heart did stop beating. I thought for a moment, and replied: “No CPR.” She said a nurse would come by shortly to place a “NO CPR” bracelet around my wrist.

My wife Sally heard this discussion, and a sideways glance revealed her distress. After the doctor left I explained that since I was in good health I was in no danger and hence the question had no practical significance. 
 
Later that evening I thought again about my decision and Sally’s reaction. I decided I might have been too hasty replying as I did. Maybe I did want CPR after all. So, I removed the CPR wristband, not an easy task, and gave it to the nurse along with a note asking to have NO CPR order rescinded. The nurse read the note and said that only the doctor could change the order. I said, okay, I’d like to speak with the doctor.
 
An hour later the doctor arrived and greeted me with a quizzical look. “So, you changed your mind?” I replied that perhaps I did but wanted her to elaborate the pros and cons of CPR. She responded with a question: “How do you want to die? Do you want a peaceful death as might occur in hospice care? Or do you want a dozen people crowded around your hospital bed, one person on top of you administering CPR while another is giving you a shot in the arm, still another is hooking you up to an IV, and yet another is jamming some tubes down your throat?”
 
She went on to explain that as we age the body begins to wear down and then wear out. Our skin becomes wrinkled and less resilient, our bones become weaker and break more easily, our organs no longer operate as effectively as they once did, and the heart—eventually it stops because it is worn out. In that case, what are the prospects for a quality life even if you can be resuscitated?  Her reasoning made good sense.
 
The doctor described a recent Canadian study on the odds of being able to resume a normal life after CPR and how the odds varied with demographic characteristics. She said that at my age, 80, the likelihood of being able to walk out of the hospital after CPR and resume a normal life is far less than 10 percent; it might be closer to zero.
 
Hearing that, I asked for another NO CPR bracelet. A moment later the nurse reappeared with a replacement “NO CPR” bracelet. I felt much better knowing what the study revealed rather than allowing emotion to govern my decision. When I later explained this to Sally, she agreed.
 
The next morning the same admitting doctor entered my room followed by a resident and several interns. She briefed the interns on my condition. After she finished, I asked her to explain the Canadian CPR study results. She turned to the group and asked: What do you think is the likelihood a man this age, age 80, who if his heart stopped beating and CPR was administered would survive and be able to return home and lead a normal life? One intern ventured a guess of 30 percent, another 50 percent. She told him the odds were less than 10 percent. They gasped in surprise.
 
Before I checked out of the hospital, the doctor gave me a copy of the Canadian study (Brindly et al). Here are the sobering results. Of the 247 hospitalized patients who received CPR following cardiac or respiratory arrest, 91 were able to be resuscitated, but only 33 survived to hospital discharge, and only 28 of them were discharged and able to return home. For patients age 80 and over, the success rate was far lower, with only one of the 42 being able to resume a normal life.
 
Another study (Bobrow et al) reported on the results of out-of-hospital CPR. Of the 4415 who received bystander CPR, only 310 (7.1 percent) survived to hospital discharge. Of the 217 for whom neurologic information was available, approximately one-third of them (31.1 percent) suffered some form of neurologic damage, including moderate cerebral disability, severe cerebral disability, or coma or vegetative state.
 
A nurse later told me most patients don’t know enough to make an informed decision about CPR. Families are usually so eager to keep their loved ones alive that they insist on CPR even when hospital personnel doubt its effectiveness. Though administering CPR may extend life, it is usually a life of much diminished quality. That’s what family members don’t realize.
 
The clincher came when after returning home I checked Google for more information. What stood out was this. In popular television programs two-thirds of hospital patients who receive CPR survive and live happily ever after (Diem et al). What a contrast to the reality of hospital experience with its vastly lower full recovery rates.
 
Next time they cart me off  to a hospital, there will be no hesitation. Give me a bracelet, saying “No CPR, Please!” If I am unable to speak, the metallic “No CPR” bracelet on my right wrist will speak for me.

References:
Bentley J. Bobrow, Daniel W. Spaite, Robert A. Berg, et al. Chest Compression only CPR by Lay Rescuers and Survival from Out-of-Hospital Cardiac Arrest. JAMA. 2010;304(13):1447-1454 (doi:10.1001/jama.2010.1392).
 
Peter G. Brindley, Darren M. Markland, Irvin Mayers, and Demetrios J. Kutsogiannis. Predictors of survival following in-hospital adult cardiopulmonary resuscitation. CMAJ/2002:167(4)):343-8.
 
Susan J. Diem, M.D., M.P.H., John D. Lantos, M.D., and James A. Tulsky, M.D. Cardiopulmonary Resuscitation on Television — Miracles and Misinformation.
N Engl J Med, 1996; 334:1578-82.