IDEAS AND O pin io n s
Annals of Internal Medicine
Moving to High-Value Care: More Thoughtful Use of Cardiopulmonary Resuscitation Frank H. Bosch, MD, PhD, and David A. Fleming, MD, MA
ince Safar and colleagues first described m outh-tom outh ventilation in 1958 (1) and Kouwenhoven and colleagues described closed-chest cardiac mas sage in 1960 (2), many changes in technique and p ro to col have im proved outcom es o f cardiopulm onary re suscitation (CPR) (3). All hospitals have a CPR team in place, and autom ated external defibrillators (AEDs) are om nipresent in p ub lic spaces in the developed w orld. O ften a dram atic event w ithin health care settings, CPR has been fu rthe r dram atized in movies and television shows. In real life, physicians perform this ritual in hospitals repeatedly and reflexively. Too often we perform it re gardless o f prognosis, w ith o u t know ing w hether the patient desires it, and know ing that we may do harm. C onvention is that, w itho ut an explicit do-not-resuscitate order, consent fo r CPR is im plicit. This practice assumes that m ost reasonable persons w ould o p t fo r this p o te n tially life-saving em ergency intervention. However, d e p ending on the underlying diagnosis, the circumstance in which cardiac arrest occurs, patient age, and com orbid conditions, the outcom e o f CPR is typically dismal. Studies show th a t up to 20% o f patients with in-hospital cardiac arrest w ho receive CPR survive to hospital dis charge (4). However, outcom e depends on the circum stances. W hen an otherwise healthy, m iddle-aged pa tie n t has a coronary event with a subsequent witnessed ventricular fib rilla tio n arrest in a hospital, there is a strong indication fo r CPR because the chances o f lo n g term survival after CPR may be sim ilar to a patient who did not have a cardiac arrest (5). However, a hospital ized elderly patient with m etastatic cancer w ho has car diac arrest with a rhythm that is not ventricular fib rilla tion has a small chance o f survival to discharge and a high p ro b a b ility o f injury during CPR and significant functional im pairm ent if they survive (6). Patients are also at risk fo r life-changing im pairm ent if they survive the acute resuscitation event. The key question then is w hether the patient, under his or her specific circum stances, wants to undergo CPR or o the r aggressive lifesustaining treatm ents should the likelihood o f survival be p o o r or chance o f harm and d e b ility high. To answer this question, we must begin discussions early to e du cate patients abo ut the realistic prognosis o f patients like them w ho receive CPR and seek th e ir partnership in d eciding w hether CPR is in th e ir best interest. The im petus to perform CPR springs from m ultiple sources: the lure to use technical treatm ent ap proaches, the fear o f being ju d g e d professionally or sued if the patient dies w ith o u t a resuscitation attem pt, and overoptim ism about prognosis after CPR am ong both clinicians and patients. A ckn ow le dg m e nt that pa
S
This article was published online first at www.annals.org on 7 April 2015. 790 © 2015 American College of Physicians
tients may prefer death to aggressive, life-sustaining in terventions has led to an increasing acceptance that CPR may not be indicated fo r many patients. Yet, per haps because we and our patients w orry th a t do-notresuscitate status may have a negative influence on the quality o f care and attention that patients receive in hospitals, many patients fo r whom CPR is unlikely to help end up g ettin g this intervention by default. The recent Institute o f M edicine (IOM ) re p o rt "D y ing in Am erica: Im proving Q uality and H onoring Indi vidual Preferences Near the End o f Life" offers a m odel o f care fo r patients with advanced illness, stating that it should be seamless, high-quality, integrated, patientand fam ily-centered, and consistently available (7). Those trained and skilled in giving such care should also deliver it. The IOM advises us to com m unicate b e t te r about prognosis and clinical options. Having discus sions a bo ut preferences regarding end-of-life care early in the course o f illness makes it m ore likely that care will be consistent with patient goals. The fear that end-of-life discussions increase depression or anxiety or cause the patient to lose hope is unfounded (8). Hospitals must be environm ents w here d e te rio ra t ing vital signs are evaluated quickly, patients w ill not have acute events unnoticed, and CPR is perform ed only when clinically indicated, on the basis o f patient preferences and the realistic chances o f benefit. This may seem self-evident. A lth ou g h our awareness o f these issues is im proving, health care teams often still do not know w hether th e ir patients w ant CPR. A recent story in Annals G raphic M edicine pow erfully illustrates the problem (9). C ardiopulm onary resuscitation opens the d o o r to a cascade o f other aggressive interventions and ques tions. A fter CPR, patients w ho have a return o f sponta neous circulation will be transferred to an intensive care unit. W ill dialysis be instituted if renal function declines? Do we add pressors, antibiotics, or o the r treatm ent when the clinical situation is clearly and u nrem ittingly declining? Because o f the technological advances in m edicine, w hether to initiate CPR and the cascade of com plex levels o f trea tm en t that can fo llo w it must be part o f every discussion in the face o f a life-altering d i agnosis. Yet, w hile physicians have been w riting and talking a bo ut this issue fo r decades, we to o often fail to practice in accord with these sentiments. Discussions a bo ut CPR and other aggressive inter ventions must be an integral part o f physicians' discus sions with patients at the tim e o f hospitalization, and the results o f these discussions must be d ocum ented in the health record and im m ediately available to the en-
I deas and O pinions
Moving to High-Value Care: More Thoughtful Use of CPR tire care team . Discussion should occur at every hospi talization even with patients w ho have an advance directive in place. Advance directives are living d ocu ments that may change with tim e because o f evolving preferences and clinical circumstances. Discussions need to be initiated early and continually updated, par ticularly at the tim e o f hospitalization, so that the pa tient, care team , and fam ily have full understanding of the a p p ro priate action should a cardiac arrest occur. Hospitals must be environm ents where patients routinely learn a bo ut th e ir options and prognosis and express th e ir preferences. In an era when we are striv ing fo r b etter value in health care (10), we must be frank with ourselves and our patients th a t CPR often offers lim ited value. These are all messages heard before. But they rem ain essential-and the persistence o f these problem s dem ands that we continue to rem ind o u r selves. T ogether, patients and physicians can enhance the a p p ro priate use o f CPR by recognizing the lim its o f w hat it offers some patients and gaining a better under standing o f our patients' preferences. From Rijnstate Hospital, Arnhem , the Netherlands, and Uni versity o f Missouri School of M edicine, C olum bia, Missouri.
Ann Intern Med. 2015;162:790-791. d o i:1 0 .7 3 2 6 /M 1 5-0492
R eferences 1. Safar P, Escarraga LA, Elam JO. A comparison of the mouth-tomouth and mouth-to-airway methods of artificial respiration with the chest-pressure arm-lift methods. N Engl J Med. 1958;258:671-7. [PMID: 13526920] 2. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest car diac massage. JAMA. 1960;173:1064-7. [PMID: 14411374] 3. Chan PS, McNally B, Tang F, Kellermann A; CARES Surveillance Group. Recent trends in survival from out-of-hospital cardiac arrest in the United States. Circulation. 2014;130:1876-82. [PMID: 25399396] doi: 10.1161/CIRCULATIONAHA.114.009711 4. Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS; American Heart Association Get with the Guidelines Resuscita tion Investigators. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367:1912-20. [PMID: 23150959] doi:10.1056 /NEJMoal 109148 5. Alahmar AE, Nelson CP, Snell Kl, Yuyun MF, Musameh MD, Timmis A, et al. Resuscitated cardiac arrest and prognosis following myocardial infarction. Heart. 2014;100:1125-32. [PMID: 24763491] doi:10.1136/heartjnl-2014-305696 6. Stapleton RD, Ehlenbach WJ, Deyo RA, Curtis JR. Long-term out comes after in-hospital CPR in older adults with chronic illness. Chest. 2014;146:1214-25. [PMID: 25086252] doi:10.1378/chest,13
-2110 Disclosures: A uthors have disclosed no conflicts o f interest. Forms can be view ed at w w w .acpo nline .org/au thors/icm je /C o n flictO fln te re stF o rm s.d o ? m sN u m = M 1 5-0492. Requests for Single Reprints: Frank H. Bosch, MD, PhD, Rijn state H ospital, D e pa rtm e nt o f Internal M edicine, PO Box 9555, 6800 TA A rnhem , the N etherlands; e-mail, fhbosch@ gm ail.com . C urrent a u thor addresses and au thor con tribu tions are avail able at w w w .annals.org.
w w w .a n n a ls .o rg
7. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academies Pr; 2014. 8. Pizzo PA. The Doctor, for life and at the end of life. Ann Intern Med. 2015;162:228-9. [PMID: 25486216] doi:10.7326/M14-2399 9. Green MJ, Rieck R. Annals Graphic Medicine: Betty P. Ann Intern Med. 2015;162:W74-9. [PMID: 25845018] doi:10.7326/G14-0009 10. Smith CD; Alliance for Academic Internal Medicine-American College of Physicians High Value, Cost-Conscious Care Curriculum Development Committee. Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine-American College of Physicians curriculum. Ann Intern Med. 2012;157:284-6. [PMID: 22777503] doi: 10.7326/0003-4819-157-4-201208210-00496
Annals of Internal Medicine • Vol. 162 No. 11 • 2 June 2015 791
Copyright © American College of Physicians 2015.
Annals of Internal Medicine
Moving to High-Value Care: More Thoughtful Use of Cardiopulmonary Resuscitation Frank H. Bosch, MD, PhD, and David A. Fleming, MD, MA
ince Safar and colleagues first described m outh-tom outh ventilation in 1958 (1) and Kouwenhoven and colleagues described closed-chest cardiac mas sage in 1960 (2), many changes in technique and p ro to col have im proved outcom es o f cardiopulm onary re suscitation (CPR) (3). All hospitals have a CPR team in place, and autom ated external defibrillators (AEDs) are om nipresent in p ub lic spaces in the developed w orld. O ften a dram atic event w ithin health care settings, CPR has been fu rthe r dram atized in movies and television shows. In real life, physicians perform this ritual in hospitals repeatedly and reflexively. Too often we perform it re gardless o f prognosis, w ith o u t know ing w hether the patient desires it, and know ing that we may do harm. C onvention is that, w itho ut an explicit do-not-resuscitate order, consent fo r CPR is im plicit. This practice assumes that m ost reasonable persons w ould o p t fo r this p o te n tially life-saving em ergency intervention. However, d e p ending on the underlying diagnosis, the circumstance in which cardiac arrest occurs, patient age, and com orbid conditions, the outcom e o f CPR is typically dismal. Studies show th a t up to 20% o f patients with in-hospital cardiac arrest w ho receive CPR survive to hospital dis charge (4). However, outcom e depends on the circum stances. W hen an otherwise healthy, m iddle-aged pa tie n t has a coronary event with a subsequent witnessed ventricular fib rilla tio n arrest in a hospital, there is a strong indication fo r CPR because the chances o f lo n g term survival after CPR may be sim ilar to a patient who did not have a cardiac arrest (5). However, a hospital ized elderly patient with m etastatic cancer w ho has car diac arrest with a rhythm that is not ventricular fib rilla tion has a small chance o f survival to discharge and a high p ro b a b ility o f injury during CPR and significant functional im pairm ent if they survive (6). Patients are also at risk fo r life-changing im pairm ent if they survive the acute resuscitation event. The key question then is w hether the patient, under his or her specific circum stances, wants to undergo CPR or o the r aggressive lifesustaining treatm ents should the likelihood o f survival be p o o r or chance o f harm and d e b ility high. To answer this question, we must begin discussions early to e du cate patients abo ut the realistic prognosis o f patients like them w ho receive CPR and seek th e ir partnership in d eciding w hether CPR is in th e ir best interest. The im petus to perform CPR springs from m ultiple sources: the lure to use technical treatm ent ap proaches, the fear o f being ju d g e d professionally or sued if the patient dies w ith o u t a resuscitation attem pt, and overoptim ism about prognosis after CPR am ong both clinicians and patients. A ckn ow le dg m e nt that pa
S
This article was published online first at www.annals.org on 7 April 2015. 790 © 2015 American College of Physicians
tients may prefer death to aggressive, life-sustaining in terventions has led to an increasing acceptance that CPR may not be indicated fo r many patients. Yet, per haps because we and our patients w orry th a t do-notresuscitate status may have a negative influence on the quality o f care and attention that patients receive in hospitals, many patients fo r whom CPR is unlikely to help end up g ettin g this intervention by default. The recent Institute o f M edicine (IOM ) re p o rt "D y ing in Am erica: Im proving Q uality and H onoring Indi vidual Preferences Near the End o f Life" offers a m odel o f care fo r patients with advanced illness, stating that it should be seamless, high-quality, integrated, patientand fam ily-centered, and consistently available (7). Those trained and skilled in giving such care should also deliver it. The IOM advises us to com m unicate b e t te r about prognosis and clinical options. Having discus sions a bo ut preferences regarding end-of-life care early in the course o f illness makes it m ore likely that care will be consistent with patient goals. The fear that end-of-life discussions increase depression or anxiety or cause the patient to lose hope is unfounded (8). Hospitals must be environm ents w here d e te rio ra t ing vital signs are evaluated quickly, patients w ill not have acute events unnoticed, and CPR is perform ed only when clinically indicated, on the basis o f patient preferences and the realistic chances o f benefit. This may seem self-evident. A lth ou g h our awareness o f these issues is im proving, health care teams often still do not know w hether th e ir patients w ant CPR. A recent story in Annals G raphic M edicine pow erfully illustrates the problem (9). C ardiopulm onary resuscitation opens the d o o r to a cascade o f other aggressive interventions and ques tions. A fter CPR, patients w ho have a return o f sponta neous circulation will be transferred to an intensive care unit. W ill dialysis be instituted if renal function declines? Do we add pressors, antibiotics, or o the r treatm ent when the clinical situation is clearly and u nrem ittingly declining? Because o f the technological advances in m edicine, w hether to initiate CPR and the cascade of com plex levels o f trea tm en t that can fo llo w it must be part o f every discussion in the face o f a life-altering d i agnosis. Yet, w hile physicians have been w riting and talking a bo ut this issue fo r decades, we to o often fail to practice in accord with these sentiments. Discussions a bo ut CPR and other aggressive inter ventions must be an integral part o f physicians' discus sions with patients at the tim e o f hospitalization, and the results o f these discussions must be d ocum ented in the health record and im m ediately available to the en-
I deas and O pinions
Moving to High-Value Care: More Thoughtful Use of CPR tire care team . Discussion should occur at every hospi talization even with patients w ho have an advance directive in place. Advance directives are living d ocu ments that may change with tim e because o f evolving preferences and clinical circumstances. Discussions need to be initiated early and continually updated, par ticularly at the tim e o f hospitalization, so that the pa tient, care team , and fam ily have full understanding of the a p p ro priate action should a cardiac arrest occur. Hospitals must be environm ents where patients routinely learn a bo ut th e ir options and prognosis and express th e ir preferences. In an era when we are striv ing fo r b etter value in health care (10), we must be frank with ourselves and our patients th a t CPR often offers lim ited value. These are all messages heard before. But they rem ain essential-and the persistence o f these problem s dem ands that we continue to rem ind o u r selves. T ogether, patients and physicians can enhance the a p p ro priate use o f CPR by recognizing the lim its o f w hat it offers some patients and gaining a better under standing o f our patients' preferences. From Rijnstate Hospital, Arnhem , the Netherlands, and Uni versity o f Missouri School of M edicine, C olum bia, Missouri.
Ann Intern Med. 2015;162:790-791. d o i:1 0 .7 3 2 6 /M 1 5-0492
R eferences 1. Safar P, Escarraga LA, Elam JO. A comparison of the mouth-tomouth and mouth-to-airway methods of artificial respiration with the chest-pressure arm-lift methods. N Engl J Med. 1958;258:671-7. [PMID: 13526920] 2. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest car diac massage. JAMA. 1960;173:1064-7. [PMID: 14411374] 3. Chan PS, McNally B, Tang F, Kellermann A; CARES Surveillance Group. Recent trends in survival from out-of-hospital cardiac arrest in the United States. Circulation. 2014;130:1876-82. [PMID: 25399396] doi: 10.1161/CIRCULATIONAHA.114.009711 4. Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS; American Heart Association Get with the Guidelines Resuscita tion Investigators. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367:1912-20. [PMID: 23150959] doi:10.1056 /NEJMoal 109148 5. Alahmar AE, Nelson CP, Snell Kl, Yuyun MF, Musameh MD, Timmis A, et al. Resuscitated cardiac arrest and prognosis following myocardial infarction. Heart. 2014;100:1125-32. [PMID: 24763491] doi:10.1136/heartjnl-2014-305696 6. Stapleton RD, Ehlenbach WJ, Deyo RA, Curtis JR. Long-term out comes after in-hospital CPR in older adults with chronic illness. Chest. 2014;146:1214-25. [PMID: 25086252] doi:10.1378/chest,13
-2110 Disclosures: A uthors have disclosed no conflicts o f interest. Forms can be view ed at w w w .acpo nline .org/au thors/icm je /C o n flictO fln te re stF o rm s.d o ? m sN u m = M 1 5-0492. Requests for Single Reprints: Frank H. Bosch, MD, PhD, Rijn state H ospital, D e pa rtm e nt o f Internal M edicine, PO Box 9555, 6800 TA A rnhem , the N etherlands; e-mail, fhbosch@ gm ail.com . C urrent a u thor addresses and au thor con tribu tions are avail able at w w w .annals.org.
w w w .a n n a ls .o rg
7. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academies Pr; 2014. 8. Pizzo PA. The Doctor, for life and at the end of life. Ann Intern Med. 2015;162:228-9. [PMID: 25486216] doi:10.7326/M14-2399 9. Green MJ, Rieck R. Annals Graphic Medicine: Betty P. Ann Intern Med. 2015;162:W74-9. [PMID: 25845018] doi:10.7326/G14-0009 10. Smith CD; Alliance for Academic Internal Medicine-American College of Physicians High Value, Cost-Conscious Care Curriculum Development Committee. Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine-American College of Physicians curriculum. Ann Intern Med. 2012;157:284-6. [PMID: 22777503] doi: 10.7326/0003-4819-157-4-201208210-00496
Annals of Internal Medicine • Vol. 162 No. 11 • 2 June 2015 791
Copyright © American College of Physicians 2015.
